Provider Demographics
NPI:1396122065
Name:QUALLICH, DANIELLE (MD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:QUALLICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:MARIE
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2450 RIVERSIDE AVE
Mailing Address - Street 2:6TH FLOOR EAST BUILDING
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:612-624-4477
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:1ST FLOOR EAST BUILDING
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454
Practice Address - Country:US
Practice Address - Phone:612-624-4477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN63250208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program