1215065297 NPI number — DIANNE C DANIELS SW

Table of content: DIANNE C DANIELS SW (NPI 1215065297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215065297 NPI number — DIANNE C DANIELS SW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DANIELS
Provider First Name:
DIANNE
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215065297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 BRADBURY DR SE STE 116
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87106-4310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-272-1476
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7801 WILSHIRE AVE NE
Provider Second Line Business Practice Location Address:
LA CUEVA HS
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87122-2807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-823-2327
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041S0200X , with the licence number:  I 0044 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: I 0044 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: H 3128 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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