Provider Demographics
NPI:1366400293
Name:BLACKWELL, DANIELLE LEYLA (FNP)
Entity type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:LEYLA
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 MOLALLA AVE
Mailing Address - Street 2:SUITE AB
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045
Mailing Address - Country:US
Mailing Address - Phone:503-656-9030
Mailing Address - Fax:503-656-9026
Practice Address - Street 1:19723 S HWY 213
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-4190
Practice Address - Country:US
Practice Address - Phone:503-656-9030
Practice Address - Fax:503-656-9026
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200150108NPFNPPP363L00000X
OR200150108NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR262804Medicaid
ORP67176Medicare UPIN
OR262804Medicaid
OR113998Medicare ID - Type Unspecified
113998Medicare ID - Type Unspecified