Healthcare Provider Details

I. General information

NPI: 1053648063
Provider Name (Legal Business Name): DANIELLE E SIEDSCHLAG APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N HARLEM AVE
FREEPORT IL
61032-3801
US

IV. Provider business mailing address

421 W EXCHANGE ST PO BOX 268
FREEPORT IL
61032-4008
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-7750
  • Fax:
Mailing address:
  • Phone: 815-599-7958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number209007872
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: