Healthcare Provider Details

I. General information

NPI: 1457708109
Provider Name (Legal Business Name): DANIELLE OTIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANIELLE SHOULDICE PA-C

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 11/27/2023
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST STE M-124
KALAMAZOO MI
49007-5377
US

IV. Provider business mailing address

221 22ND ST S
BATTLE CREEK MI
49015-3007
US

V. Phone/Fax

Practice location:
  • Phone: 269-341-7500
  • Fax:
Mailing address:
  • Phone: 269-579-3499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601007780
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: