Provider Demographics
NPI:1649691221
Name:DANIELS, LINDA
Entity type:Individual
Prefix:MISS
First Name:LINDA
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:DORRETTE
Other - Middle Name:
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2573 RAVENHILL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2573 RAVENHILL DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303
Practice Address - Country:US
Practice Address - Phone:910-488-7548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200002383091174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist