Healthcare Provider Details

I. General information

NPI: 1679252282
Provider Name (Legal Business Name): DANIELLE NIGHTSHADE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 3RD ST
TILLAMOOK OR
97141-3430
US

IV. Provider business mailing address

980 3RD ST STE 200
TILLAMOOK OR
97141-9469
US

V. Phone/Fax

Practice location:
  • Phone: 503-842-4444
  • Fax: 503-815-7429
Mailing address:
  • Phone: 503-842-4444
  • Fax: 503-815-7429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4425
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: