Provider Demographics
NPI:1215412416
Name:DANIELS, DEMETRIS
Entity type:Individual
Prefix:
First Name:DEMETRIS
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6723
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:18610 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2378
Practice Address - Country:US
Practice Address - Phone:313-723-6000
Practice Address - Fax:134-244-0583
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704227963363LF0000X
MIF08180197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine