Basic Information
| Provider Information | |||||||||
| NPI: | 1740646892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZ | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAX | ||||||||
| OtherFirstName: | DANIELLE | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPN | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 507 OLD AGENCY DR | ||||||||
| Address2: | UNIT 137A | ||||||||
| City: | SISSETON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572627226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056987606 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 507 OLD AGENCY DR | ||||||||
| Address2: | UNIT 137A | ||||||||
| City: | SISSETON | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572627226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056987606 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2016 | ||||||||
| LastUpdateDate: | 01/05/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | MN-68919-1 | MN | N | Nursing Service Providers | Licensed Practical Nurse | 164W00000X | P011829 | SD | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.