Healthcare Provider Details

I. General information

NPI: 1649519794
Provider Name (Legal Business Name): BETTY JEAN DANIELS CERTIFIED MED TECH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2013
Last Update Date: 02/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 N 36TH ST
MILWAUKEE WI
53210-3041
US

IV. Provider business mailing address

2514 N 36TH ST
MILWAUKEE WI
53210-3041
US

V. Phone/Fax

Practice location:
  • Phone: 414-628-3853
  • Fax:
Mailing address:
  • Phone: 414-628-3853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License NumberNA205392
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberNA205392
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: