Provider Demographics
NPI:1962075382
Name:SMITH, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:SMITH
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 1:111 N 6TH ST STE G1
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-3320
Mailing Address - Country:US
Mailing Address - Phone:309-810-4407
Mailing Address - Fax:309-354-2041
Practice Address - Street 1:111 N 6TH ST STE G1
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-3320
Practice Address - Country:US
Practice Address - Phone:309-810-4407
Practice Address - Fax:309-354-2041
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2025-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023572363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health