Provider Demographics
NPI:1790946853
Name:WICKLOW, DANIELLE GERMAIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:GERMAIN
Last Name:WICKLOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 E MCDOWELL RD
Mailing Address - Street 2:DEPT. OF INTERNAL MEDICINE- CONNIE FARRINGTON
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 E MCDOWELL RD
Practice Address - Street 2:DEPT. OF INTERNAL MEDICINE- CONNIE FARRINGTON
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2612
Practice Address - Country:US
Practice Address - Phone:602-239-2296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-21
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ70820207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ146448Medicare PIN