Healthcare Provider Details

I. General information

NPI: 1033414636
Provider Name (Legal Business Name): DANIELLE FAY THOMPSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANIELLE FAY RODRIGUEZ PA-C

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 W FAIRBANKS AVE
WINTER PARK FL
32789-4327
US

IV. Provider business mailing address

118 W FAIRBANKS AVE
WINTER PARK FL
32789-4327
US

V. Phone/Fax

Practice location:
  • Phone: 407-646-2235
  • Fax:
Mailing address:
  • Phone: 407-646-2235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105684
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: