Healthcare Provider Details

I. General information

NPI: 1760307946
Provider Name (Legal Business Name): DANIELLE KRISTINE ILLINGWORTH
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 30TH ST
DES MOINES IA
50310-5753
US

IV. Provider business mailing address

3600 30TH ST
DES MOINES IA
50310-5753
US

V. Phone/Fax

Practice location:
  • Phone: 515-699-5771
  • Fax:
Mailing address:
  • Phone: 515-699-5771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number123288
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: