=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871102939
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA WADE DANIEL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2020
-----------------------------------------------------
Last Update Date | 07/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2907 CYPRESS ST
-----------------------------------------------------
City | WEST MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71291-5337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-325-3142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 733 DUMMY LINE RD
-----------------------------------------------------
City | RAYVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71269-7767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-376-2136
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 015496
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------