Provider Demographics
NPI:1730634742
Name:INNISS, ASHA DANIELLA (NP)
Entity Type:Individual
Prefix:
First Name:ASHA
Middle Name:DANIELLA
Last Name:INNISS
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 1:9201 E MOUNTAIN VEW ROAD
Mailing Address - Street 2:220
Mailing Address - City:SCOTTDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1604 HOSPITAL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6930
Practice Address - Country:US
Practice Address - Phone:817-848-4485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131436363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner