Provider Demographics
NPI:1790015626
Name:HUGABOOM, DANYELLE
Entity Type:Individual
Prefix:
First Name:DANYELLE
Middle Name:
Last Name:HUGABOOM
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 1:1175 PARKMAN RD NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-2468
Mailing Address - Country:US
Mailing Address - Phone:330-367-7106
Mailing Address - Fax:
Practice Address - Street 1:1175 PARKMAN RD NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2468
Practice Address - Country:US
Practice Address - Phone:330-367-7106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-25
Last Update Date:2009-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2988889Medicaid