Provider Demographics
NPI:1609388461
Name:KING, DANIELLE LAUREN (PA-C)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LAUREN
Last Name:KING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 E HARMONY RD UNIT 330
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3403
Mailing Address - Country:US
Mailing Address - Phone:970-221-5878
Mailing Address - Fax:
Practice Address - Street 1:2500 ROCKY MOUNTAIN AVE STE 340
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9004
Practice Address - Country:US
Practice Address - Phone:970-495-7421
Practice Address - Fax:970-203-7179
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006368363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000194942Medicaid