Basic Information
| Provider Information | |||||||||
| NPI: | 1518014166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIELS | ||||||||
| FirstName: | JEREMIAH | ||||||||
| MiddleName: | WESLEY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 SOUTH 28TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012613606 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012613606 | ||||||||
| FaxNumber: | 6015795383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN9215601 | FL | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN187112 | GA | N | Nursing Service Providers | Registered Nurse | 367500000X | RN187112 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 901433 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1952395097 | 01 | GA | NORTH GEORGIA MEDICAL CENTER NPI | OTHER | 02323776 | 05 | MS | MEDICAID | RN187112 | 01 | GA | RN LICENSE | OTHER | 58-1896463 | 01 | GA | NORTH GEORGIA MEDICAL CENTER, TAX ID | OTHER |