Provider Demographics
NPI:1205924636
Name:BRENNO-WATTERUD, DANIELLE J (OD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:J
Last Name:BRENNO-WATTERUD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 15TH AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-3800
Mailing Address - Country:US
Mailing Address - Phone:701-577-3937
Mailing Address - Fax:701-577-3938
Practice Address - Street 1:1213 15TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3800
Practice Address - Country:US
Practice Address - Phone:701-577-3937
Practice Address - Fax:701-577-3938
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND590152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60544Medicaid
U83457Medicare UPIN
ND60544Medicaid