Provider Demographics
NPI:1447995352
Name:POULOS, DANIELLE PATRICE (FNP-C)
Entity type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:PATRICE
Last Name:POULOS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13011 S 104TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1508
Mailing Address - Country:US
Mailing Address - Phone:708-478-3600
Mailing Address - Fax:708-478-3552
Practice Address - Street 1:13011 S 104TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1508
Practice Address - Country:US
Practice Address - Phone:708-274-3278
Practice Address - Fax:708-274-3299
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025382363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily