MEDICARE: DANIELLE NICOLE LODGE

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	363AM0700X	Medical Physician Assistant	0110011717	VA

General Provider Information

NPI Number	:	1699626515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE NICOLE LODGE

Provider Business Mailing Address
First Line	:	205 WELLINGTON RD
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29485-5146
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	582 BLUE RIDGE AVE
Second Line	:
City	:	BEDFORD
State	:	VA
Zip	:	24523-2604
Country	:	US
Telephone Number	:	540-425-7910
Fax Number	:

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

Provider Enumeration Date	:	02/06/2026
Last Update Date	:	02/06/2026

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Directions to “ DANIELLE NICOLE LODGE ” Practice Location

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