Provider Demographics
NPI:1407690050
Name:DETJENS, DANIELLA DARLENE
Entity type:Individual
Prefix:
First Name:DANIELLA
Middle Name:DARLENE
Last Name:DETJENS
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 1:1126 E PALO VERDE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2247
Mailing Address - Country:US
Mailing Address - Phone:602-642-0161
Mailing Address - Fax:
Practice Address - Street 1:2415 E UNION HILLS DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-3146
Practice Address - Country:US
Practice Address - Phone:602-867-0561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS027033183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist