Healthcare Provider Details

I. General information

NPI: 1750913521
Provider Name (Legal Business Name): DANIELLE MARIE FLYTHE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DANIELLE MARIE RUCKER

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SAVAGE RD
CORAPEAKE NC
27926-9684
US

IV. Provider business mailing address

400 SAVAGE RD
CORAPEAKE NC
27926-9684
US

V. Phone/Fax

Practice location:
  • Phone: 708-606-4551
  • Fax:
Mailing address:
  • Phone: 708-606-4551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024178828
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: