Provider Demographics
NPI:1366164659
Name:FLETCHER, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-0123
Mailing Address - Country:US
Mailing Address - Phone:320-654-6711
Mailing Address - Fax:
Practice Address - Street 1:400 33RD AVE N SUITE 390
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-5638
Practice Address - Country:US
Practice Address - Phone:320-654-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNBC719405171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor