Provider Demographics
NPI:1831666841
Name:DEFOTO, DANIELLE (PA)
Entity Type:Individual
Prefix:MISS
First Name:DANIELLE
Middle Name:
Last Name:DEFOTO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 RAIDER BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-1528
Mailing Address - Country:US
Mailing Address - Phone:908-281-0221
Mailing Address - Fax:
Practice Address - Street 1:1912 STATE ROUTE 35 STE 101
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:NJ
Practice Address - Zip Code:07755-2768
Practice Address - Country:US
Practice Address - Phone:732-222-4762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-28
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00510700363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant