Provider Demographics
NPI:1750913521
Name:FLYTHE, DANIELLE MARIE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:FLYTHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:MARIE
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 SAVAGE RD
Mailing Address - Street 2:
Mailing Address - City:CORAPEAKE
Mailing Address - State:NC
Mailing Address - Zip Code:27926-9684
Mailing Address - Country:US
Mailing Address - Phone:708-606-4551
Mailing Address - Fax:
Practice Address - Street 1:400 SAVAGE RD
Practice Address - Street 2:
Practice Address - City:CORAPEAKE
Practice Address - State:NC
Practice Address - Zip Code:27926-9684
Practice Address - Country:US
Practice Address - Phone:708-606-4551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178828363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner