Healthcare Provider Details

I. General information

NPI: 1083091359
Provider Name (Legal Business Name): DANIELLE CASILLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 UNSER BLVD SE
RIO RANCHO NM
87124-6377
US

IV. Provider business mailing address

5904 HOLLY AVE NE
ALBUQUERQUE NM
87113-2472
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-2505
  • Fax:
Mailing address:
  • Phone: 505-298-2505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCNP-02663
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRN--69713
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: