Provider Demographics
NPI:1669450748
Name:SMITH, DANIELLE MICHEL (NP)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:MICHEL
Last Name:SMITH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23300 ECORSE RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-1768
Mailing Address - Country:US
Mailing Address - Phone:313-291-9500
Mailing Address - Fax:313-291-6694
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:ISU-OBS
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48123-4089
Practice Address - Country:US
Practice Address - Phone:313-982-5770
Practice Address - Fax:313-982-5771
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704194031363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4559012Medicaid
MI10-4559021Medicaid
MI10-4559030Medicaid
MI10-4559040Medicaid
11712584OtherCAQH
MI10-4636630Medicaid
MI10-4559059Medicaid
11712584OtherCAQH
MI10-4559021Medicaid
MIQ03924Medicare UPIN
MIP00067565Medicare ID - Type UnspecifiedRAILROAD
MI10-4636630Medicaid