Basic Information
| Provider Information | |||||||||
| NPI: | 1790921633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAULIEU | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1095 PROFILE RD | ||||||||
| Address2: | |||||||||
| City: | FRANCONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035804938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034442464 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1095 PROFILE RD STE B | ||||||||
| Address2: | |||||||||
| City: | FRANCONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034442464 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2008 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0707 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2645 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9000407 | 01 | VT | VT MEDICAID | OTHER | 30337178 | 05 | NH | MEDICAID |