Provider Demographics
NPI:1245649029
Name:DANIELS, MARK (PCNP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DANIELS
Suffix:
Gender:M
Credentials:PCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1412
Mailing Address - Fax:360-729-3025
Practice Address - Street 1:340 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439
Practice Address - Country:US
Practice Address - Phone:541-902-1634
Practice Address - Fax:541-902-9702
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM53268363LP0808X
OR201402362RN163WP0807X
OR201810942NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent