Basic Information
| Provider Information | |||||||||
| NPI: | 1417991092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | DAVIDA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 328 | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511020328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122795830 | ||||||||
| FaxNumber: | 7122795883 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511051485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122586780 | ||||||||
| FaxNumber: | 7122580143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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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 | 207Q00000X | 31352 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1131003 | 05 | IA | MEDICAID | 48631 | 01 | IA | WELLMARK BCBS IA | OTHER | 7784540 | 05 | IA | MEDICAID | 42128384914 | 05 | IA | MEDICAID |