Healthcare Provider Details

I. General information

NPI: 1265691703
Provider Name (Legal Business Name): DEBRA J. DANIELS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 WESTERN AVE
SOUTH PORTLAND ME
04106-1705
US

IV. Provider business mailing address

5080 SPECTRUM DR SUITE 1200 WEST
ADDISON TX
75001-4648
US

V. Phone/Fax

Practice location:
  • Phone: 123-456-7890
  • Fax:
Mailing address:
  • Phone: 800-232-3550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberR021434
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: