Provider Demographics
NPI:1174881205
Name:MCDANIEL, EMMYLOU K (NP)
Entity type:Individual
Prefix:
First Name:EMMYLOU
Middle Name:K
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:EMMYLOU
Other - Middle Name:
Other - Last Name:WOOLFITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1802 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7357
Mailing Address - Country:US
Mailing Address - Phone:540-772-3485
Mailing Address - Fax:540-772-3486
Practice Address - Street 1:1802 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7357
Practice Address - Country:US
Practice Address - Phone:540-772-3485
Practice Address - Fax:540-772-3486
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV77925363LP0808X
VA0024170044363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174881205Medicaid
VA1174881205Medicaid
VAP01093083Medicare PIN