Provider Demographics
NPI:1437535713
Name:RIDDICK, DANIELLE CARROLL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:CARROLL
Last Name:RIDDICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:DANIELLE
Other - Middle Name:CARROLL
Other - Last Name:CEBAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3451 PINE RIDGE RD BLDG 601
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-3922
Mailing Address - Country:US
Mailing Address - Phone:239-449-3072
Mailing Address - Fax:877-334-1886
Practice Address - Street 1:1250 PINE RIDGE RD STE 202
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-8913
Practice Address - Country:US
Practice Address - Phone:239-325-1135
Practice Address - Fax:239-325-1205
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114620363A00000X
NC0010-05842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant