Basic Information
| Provider Information | |||||||||
| NPI: | 1730728619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIELS | ||||||||
| FirstName: | JAMAL | ||||||||
| MiddleName: | |||||||||
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| Credential: | AGACNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ATHARI | ||||||||
| OtherFirstName: | JAMAL | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11 SQUAW HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | ASHFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062781546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604555781 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 80 SEYMOUR ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061028000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609729047 | ||||||||
| FaxNumber: | 8609727040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/25/2019 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 9064 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 163WE0003X | 10.126810 | CT | N | Nursing Service Providers | Registered Nurse | Emergency |
No ID Information.