MEDICARE: ASHA DANIELLA INNISS NP

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	363L00000X	Nurse Practitioner	AP131436	TX
2	363LG0600X	Gerontology Nurse Practitioner	AP131436	TX

General Provider Information

NPI Number	:	1730634742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHA DANIELLA INNISS NP

Provider Business Mailing Address
First Line	:	9201 E MOUNTAIN VEW ROAD
Second Line	:	220
City	:	SCOTTDALE
State	:	AZ
Zip	:	85258
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1604 HOSPITAL PKWY STE 200
Second Line	:
City	:	BEDFORD
State	:	TX
Zip	:	76022-6930
Country	:	US
Telephone Number	:	817-848-4485
Fax Number	:

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

Provider Enumeration Date	:	08/19/2016
Last Update Date	:	08/24/2023

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