Healthcare Provider Details

I. General information

NPI: 1780247429
Provider Name (Legal Business Name): DANIELLE LEIGH BOOTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 06/02/2022
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1743 E CAMELBACK RD STE A3
PHOENIX AZ
85016-4015
US

IV. Provider business mailing address

7797 W PARADISE LN
PEORIA AZ
85382-5009
US

V. Phone/Fax

Practice location:
  • Phone: 602-325-5114
  • Fax:
Mailing address:
  • Phone: 623-547-7502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8026
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: