Provider Demographics
NPI:1861958886
Name:KOPECKI, DANIELLE STEFANIA
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:STEFANIA
Last Name:KOPECKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 TROY SCHENECTADY RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1020
Mailing Address - Country:US
Mailing Address - Phone:518-346-2358
Mailing Address - Fax:
Practice Address - Street 1:1214 TROY SCHENECTADY RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110
Practice Address - Country:US
Practice Address - Phone:518-346-2358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY023649363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program