Provider Demographics
NPI:1962001263
Name:THREADGILL, DANIELLE LEJON
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LEJON
Last Name:THREADGILL
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 1:1049 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2822
Mailing Address - Country:US
Mailing Address - Phone:415-487-2140
Mailing Address - Fax:415-487-2142
Practice Address - Street 1:1049 HOWARD ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2822
Practice Address - Country:US
Practice Address - Phone:415-487-2140
Practice Address - Fax:415-487-2142
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist