Provider Demographics
NPI:1619483609
Name:CONLEY, DANIESHIA LANAE
Entity Type:Individual
Prefix:
First Name:DANIESHIA
Middle Name:LANAE
Last Name:CONLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 HARPER AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3558
Mailing Address - Country:US
Mailing Address - Phone:313-675-0063
Mailing Address - Fax:313-822-1157
Practice Address - Street 1:4875 COPLIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2192
Practice Address - Country:US
Practice Address - Phone:313-822-1135
Practice Address - Fax:313-822-1157
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty