Provider Demographics
NPI:1316279805
Name:DANIELS, REGINA GABRIELLE (CRNA)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:GABRIELLE
Last Name:DANIELS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 VALLEY VIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6138
Mailing Address - Country:US
Mailing Address - Phone:309-762-5560
Mailing Address - Fax:309-277-1191
Practice Address - Street 1:545 VALLEY VIEW DRIVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6138
Practice Address - Country:US
Practice Address - Phone:309-762-5560
Practice Address - Fax:309-762-7351
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-096486367500000X
IL209.012784367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered