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General NPI Number Information
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NPI Number | 1104316058
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Entity Type | Individual
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Provider Name | DANIELLE MARIE SOUTHERLAND DO
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Gender | Female
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Dates
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Enumeration Date | 05/16/2018
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Last Update Date | 08/08/2022
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Provider Practice Location Address
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Address Line | 1019 SCHOOL ST
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City | LISLE
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State | IL
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Zip | 60532-1870
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Country | US
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Telephone | 630-315-8800
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Fax | 630-315-8829
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Provider Business Mailing Address
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Address Line | 1019 SCHOOL ST
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City | LISLE
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State | IL
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Zip | 60532-1870
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Country | US
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Telephone | 630-315-8800
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Fax | 630-315-8829
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 29213
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 65933
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License Number State | MN
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