Healthcare Provider Details

I. General information

NPI: 1124492723
Provider Name (Legal Business Name): DANIELLE HURST APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 E 12 MILE RD
WARREN MI
48093-3472
US

IV. Provider business mailing address

12815 WINDSOR CT
STERLING HEIGHTS MI
48313-4176
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-5000
  • Fax:
Mailing address:
  • Phone: 773-908-3509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209012878
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209012878
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209012878
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: