Provider Demographics
NPI:1821352485
Name:CLARK, DANIELLE MICHELLE (CRNA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MICHELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:MICHELLE
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3466
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25334-3466
Mailing Address - Country:US
Mailing Address - Phone:304-346-9400
Mailing Address - Fax:304-345-7320
Practice Address - Street 1:1400 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9202
Practice Address - Country:US
Practice Address - Phone:304-346-9400
Practice Address - Fax:304-345-7320
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2013-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV57187367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821352485OtherSELECTNET
WV1821352485OtherHIGHMARK OF WV
WV1821352485OtherCIGNA
WV1821352485OtherWELLSFARGO PEIA
WV9333201OtherMEDICARE GROUP
WVP01107347OtherRAILROAD MEDICARE
WV270052997002OtherHEALTHNET/TRICARE
WV3810023591Medicaid
WV1821352485OtherCOVENTRY
WV1821352485OtherCOVENTRY
WV3810023591Medicaid