Healthcare Provider Details

I. General information

NPI: 1932860731
Provider Name (Legal Business Name): DANIELLE LAUREN KINNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 N DEL PRADO ST
TRACY CA
95391-1254
US

IV. Provider business mailing address

565 N DEL PRADO ST
TRACY CA
95391-1254
US

V. Phone/Fax

Practice location:
  • Phone: 209-679-8906
  • Fax:
Mailing address:
  • Phone: 209-679-8906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60734
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: