Provider Demographics
NPI:1780967687
Name:DANIEL, SHIRLEY (NP)
Entity type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:
Last Name:DANIEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 105109
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-5109
Mailing Address - Country:US
Mailing Address - Phone:760-380-5388
Mailing Address - Fax:
Practice Address - Street 1:3RD STREET & INNER LOOP ROAD
Practice Address - Street 2:BUILDING 166, ROOM 414
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-5109
Practice Address - Country:US
Practice Address - Phone:760-380-5388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA530115163W00000X
KS116553163W00000X
KS75462363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse