MEDICARE: MRS. DANIELLE W SNODGRASS RRA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	243U00000X	Radiology Practitioner Assistant	2510	ND
2	243U00000X	Radiology Practitioner Assistant	RTS-RT-LIC-25944	MT
3	2471C3402X	Radiography Radiologic Technologist	321611
4	243U00000X	Radiology Practitioner Assistant	RA77	FL

General Provider Information

NPI Number	:	1124356647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DANIELLE W SNODGRASS RRA

Provider Business Mailing Address
First Line	:	119 FISH OR CUT BAIT RD
Second Line	:
City	:	DEFUNIAK SPRINGS
State	:	FL
Zip	:	32433-4630
Country	:	US
Telephone Number	:	706-298-9434
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 FISH OR CUT BAIT RD
Second Line	:
City	:	DEFUNIAK SPRINGS
State	:	FL
Zip	:	32433-4630
Country	:	US
Telephone Number	:	706-298-9434
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2009
Last Update Date	:	11/16/2024

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