Provider Demographics
NPI:1902632565
Name:DEGRANDE, DANIELLE (PA-C)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:DEGRANDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 STREAM BANK DR
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-9550
Mailing Address - Country:US
Mailing Address - Phone:732-856-1936
Mailing Address - Fax:
Practice Address - Street 1:110 REHILL AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2519
Practice Address - Country:US
Practice Address - Phone:908-685-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NJ25MP00897900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant