Healthcare Provider Details

I. General information

NPI: 1093256612
Provider Name (Legal Business Name): DANIELLE NICOLE FRIES AGNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 07/21/2022
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6812 STATE ROUTE 162 STE 200
MARYVILLE IL
62062-8562
US

IV. Provider business mailing address

12855 N 40 DR STE 375
SAINT LOUIS MO
63141-8657
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-0900
  • Fax: 618-288-0909
Mailing address:
  • Phone: 314-567-6071
  • Fax: 618-288-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2017007578
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209015785
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: