Healthcare Provider Details

I. General information

NPI: 1194561894
Provider Name (Legal Business Name): DANIELLA ALEJANDRA SALAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 07/02/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 W COUNTY ROAD 419
CHULUOTA FL
32766-9518
US

IV. Provider business mailing address

8580 NORTHLAKE PKWY
ORLANDO FL
32827-6918
US

V. Phone/Fax

Practice location:
  • Phone: 407-366-2890
  • Fax:
Mailing address:
  • Phone: 407-446-8329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9118959
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: