Healthcare Provider Details

I. General information

NPI: 1124356647
Provider Name (Legal Business Name): DANIELLE W SNODGRASS RRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DANNIE W SNODGRASS RRA

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 11/16/2024
Certification Date: 11/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 FISH OR CUT BAIT RD
DEFUNIAK SPRINGS FL
32433-4630
US

IV. Provider business mailing address

119 FISH OR CUT BAIT RD
DEFUNIAK SPRINGS FL
32433-4630
US

V. Phone/Fax

Practice location:
  • Phone: 706-298-9434
  • Fax:
Mailing address:
  • Phone: 706-298-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number2510
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License NumberRTS-RT-LIC-25944
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number321611
License Number State
# 4
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License NumberRA77
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: