Healthcare Provider Details

I. General information

NPI: 1194316844
Provider Name (Legal Business Name): DANIELLE VANN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 AVENIDA LAS CAMPANAS NW
LOS RANCHOS NM
87107-3204
US

IV. Provider business mailing address

6116 POJOAQUE DR NW
ALBUQUERQUE NM
87120-4475
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-0717
  • Fax:
Mailing address:
  • Phone: 505-218-3052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1595
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: