Basic Information
| Provider Information | |||||||||
| NPI: | 1174899199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSMITH | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 339 CONSORT DR | ||||||||
| Address2: | |||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630114439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363869224 | ||||||||
| FaxNumber: | 6363867679 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 S NEW BALLAS RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363869224 | ||||||||
| FaxNumber: | 6363867679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2012 | ||||||||
| LastUpdateDate: | 04/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 2014008543 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | ENROLLED | 05 | IL | MEDICAID |