Provider Demographics
NPI:1801374178
Name:CLARK, DANIELLE NICOLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:NICOLE
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:361 ROLLINGRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-2972
Mailing Address - Country:US
Mailing Address - Phone:940-453-5635
Mailing Address - Fax:
Practice Address - Street 1:915 W EXCHANGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-7018
Practice Address - Country:US
Practice Address - Phone:214-547-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2138830225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty