Provider Demographics
NPI:1174116107
Name:DEFRIES, DANIELLE MAUREEN (LPN)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MAUREEN
Last Name:DEFRIES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:MAUREEN
Other - Last Name:FALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:50 MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56520-1938
Mailing Address - Country:US
Mailing Address - Phone:218-643-3871
Mailing Address - Fax:
Practice Address - Street 1:50 MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1938
Practice Address - Country:US
Practice Address - Phone:218-643-3871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-20
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN807766164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse