Provider Demographics
NPI:1295062537
Name:BOGUE, DANIELLE L (FNP-BC)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:L
Last Name:BOGUE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:L
Other - Last Name:AVETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:BOX 215
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-391-6495
Mailing Address - Fax:
Practice Address - Street 1:1212 BROADWAY
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1960
Practice Address - Country:US
Practice Address - Phone:618-651-0022
Practice Address - Fax:618-651-0023
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-007734363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily