Provider Demographics
NPI:1427715242
Name:THERIAULT, DANIEL JOSEPH (RN, HS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOSEPH
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:RN, HS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 E 9TH ST STE 2693
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44199-2061
Mailing Address - Country:US
Mailing Address - Phone:216-902-6260
Mailing Address - Fax:216-902-6197
Practice Address - Street 1:1240 E 9TH ST STE 2693
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44199-2061
Practice Address - Country:US
Practice Address - Phone:216-902-6260
Practice Address - Fax:216-902-6197
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH486357163WC0200X
1710I1002X
A001682146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate