Provider Demographics
NPI:1679086755
Name:DEEN, DANIELLE B
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:B
Last Name:DEEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 FLORIDA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4438
Mailing Address - Country:US
Mailing Address - Phone:209-577-3388
Mailing Address - Fax:209-338-0024
Practice Address - Street 1:1541 FLORIDA AVE STE 100
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4438
Practice Address - Country:US
Practice Address - Phone:209-577-3388
Practice Address - Fax:209-338-0024
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant