Provider Demographics
NPI:1104316058
Name:SOUTHERLAND, DANIELLE MARIE (DO)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1870
Mailing Address - Country:US
Mailing Address - Phone:630-315-8800
Mailing Address - Fax:630-315-8829
Practice Address - Street 1:1019 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1870
Practice Address - Country:US
Practice Address - Phone:630-315-8800
Practice Address - Fax:630-315-8829
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29213207Q00000X
MN65933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine