Provider Demographics
NPI:1760724421
Name:DANILESON, AZALEA (LAC)
Entity Type:Individual
Prefix:
First Name:AZALEA
Middle Name:
Last Name:DANILESON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 E JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2098
Mailing Address - Country:US
Mailing Address - Phone:516-294-7204
Mailing Address - Fax:516-294-2734
Practice Address - Street 1:166 E JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2098
Practice Address - Country:US
Practice Address - Phone:516-294-7204
Practice Address - Fax:516-294-2734
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0024191171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist