Provider Demographics
NPI:1215423785
Name:DANIELS, MANDIE (RN IBCLC)
Entity type:Individual
Prefix:
First Name:MANDIE
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:RN IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 PALUXY RD
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5655
Mailing Address - Country:US
Mailing Address - Phone:817-341-9341
Mailing Address - Fax:
Practice Address - Street 1:1310 PALUXY RD
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5655
Practice Address - Country:US
Practice Address - Phone:817-579-2969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-07
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1037501163WL0100X
TXL-95187174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant