Provider Demographics
NPI:1053785519
Name:BOETTCHER WHITE, DANIELLE MEGANN (CPM)
Entity type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:MEGANN
Last Name:BOETTCHER WHITE
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 995
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-0995
Mailing Address - Country:US
Mailing Address - Phone:847-239-0817
Mailing Address - Fax:
Practice Address - Street 1:297 N 3855 E
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5124
Practice Address - Country:US
Practice Address - Phone:208-745-7571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMID-66176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife