Healthcare Provider Details

I. General information

NPI: 1548924590
Provider Name (Legal Business Name): DERRICK DILLOW FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VINCENT AVENUE, BUILDING 626 UNIT 5142
APO AP
96368
US

IV. Provider business mailing address

VINCENT AVENUE, BUILDING 626 UNIT 5142
APO AP
96368
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-4060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71015705A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: