Provider Demographics
NPI:1952981854
Name:MCDANIEL, MARK KEVIN (RN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:KEVIN
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 MARL AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-5910
Mailing Address - Country:US
Mailing Address - Phone:619-610-8188
Mailing Address - Fax:
Practice Address - Street 1:1643 MARL AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-5910
Practice Address - Country:US
Practice Address - Phone:619-610-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN494500163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
000OtherVACCINATION TN