Basic Information
Provider Information | |||||||||
NPI: | 1528547445 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REED | ||||||||
FirstName: | DANIELLE | ||||||||
MiddleName: | HAYDEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HAYDEN | ||||||||
OtherFirstName: | DANIELLE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3123 | ||||||||
Address2: |   | ||||||||
City: | ST AUGUSTINE | ||||||||
State: | FL | ||||||||
PostalCode: | 320853123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042177450 | ||||||||
FaxNumber: | 9042177483 | ||||||||
Practice Location | |||||||||
Address1: | 14810 OLD SAINT AUGUSTINE RD STE 207 | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322582558 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9042177450 | ||||||||
FaxNumber: | 9042177483 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2018 | ||||||||
LastUpdateDate: | 03/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   |   | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.