Provider Demographics
NPI:1700296324
Name:CARLSON, DANIELLE LAUREN (CRNA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LAUREN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 S HOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-3747
Mailing Address - Country:US
Mailing Address - Phone:636-233-2266
Mailing Address - Fax:
Practice Address - Street 1:5734 COVENTRY LANE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:47804-7141
Practice Address - Country:US
Practice Address - Phone:260-436-7875
Practice Address - Fax:260-432-9812
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100169367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered