Basic Information
| Provider Information | |||||||||
| NPI: | 1619483609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONLEY | ||||||||
| FirstName: | DANIESHIA | ||||||||
| MiddleName: | LANAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 HARPER AVE APT 3 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482023558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136750063 | ||||||||
| FaxNumber: | 3138221157 | ||||||||
| Practice Location | |||||||||
| Address1: | 4875 COPLIN ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138221135 | ||||||||
| FaxNumber: | 3138221157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2017 | ||||||||
| LastUpdateDate: | 12/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | MI | Y | 193200000X MULTI-SPECIALTY GROUP |
No ID Information.