Provider Demographics
NPI:1255378618
Name:MACOMBER, DANIYEL H (LD/N)
Entity type:Individual
Prefix:MS
First Name:DANIYEL
Middle Name:H
Last Name:MACOMBER
Suffix:
Gender:F
Credentials:LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W 6TH ST
Mailing Address - Street 2:MC #24
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4324
Mailing Address - Country:US
Mailing Address - Phone:904-665-2410
Mailing Address - Fax:904-630-3316
Practice Address - Street 1:4203 BELFORT RD STE 315
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1418
Practice Address - Country:US
Practice Address - Phone:904-450-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4393133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered