Healthcare Provider Details

I. General information

NPI: 1487388492
Provider Name (Legal Business Name): DARYL GENE NANALE MAGADA ACNPC-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4160
US

IV. Provider business mailing address

5001 BUELL DR
FORT WAYNE IN
46807-3205
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7001
  • Fax: 260-434-6456
Mailing address:
  • Phone: 714-814-4832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number28243886A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number71012804A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number71012804A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: