MEDICARE: MRS. SANDRA D DANIEL P.N.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	RN042208	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679615413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SANDRA D DANIEL P.N.P.

Provider Business Mailing Address
First Line	:	72 SOUTH BROAD
Second Line	:
City	:	ELLAVILLE
State	:	GA
Zip	:	31806
Country	:	US
Telephone Number	:	229-937-5321
Fax Number	:	229-937-2232

Provider Business Practice Location Address
First Line	:	72 SOUTH BROAD
Second Line	:
City	:	ELLAVILLE
State	:	GA
Zip	:	31806
Country	:	US
Telephone Number	:	229-937-5321
Fax Number	:	229-937-2232

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	07/08/2007

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