Provider Demographics
NPI:1982999223
Name:GUDMESTAD, DANIELLE MARIE (MMS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:MARIE
Last Name:GUDMESTAD
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1925 E RAND RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-4366
Mailing Address - Country:US
Mailing Address - Phone:618-979-3598
Mailing Address - Fax:847-253-3337
Practice Address - Street 1:1925 E RAND RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-4366
Practice Address - Country:US
Practice Address - Phone:618-979-3598
Practice Address - Fax:847-253-3337
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant