Provider Demographics
NPI:1205583028
Name:WAVRA, DANIELLE LYNN
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LYNN
Last Name:WAVRA
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 1:3109 E ROVEEN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-6570
Mailing Address - Country:US
Mailing Address - Phone:218-289-4291
Mailing Address - Fax:
Practice Address - Street 1:3109 E ROVEEN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-6570
Practice Address - Country:US
Practice Address - Phone:218-289-4291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20-1931175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath