Healthcare Provider Details

I. General information

NPI: 1689082174
Provider Name (Legal Business Name): KATHY DERRICK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 E PECOS RD STE 102
GILBERT AZ
85295-3201
US

IV. Provider business mailing address

4366 S AVENIDA DE ANGELES
GOLD CANYON AZ
85118-2976
US

V. Phone/Fax

Practice location:
  • Phone: 480-690-8412
  • Fax:
Mailing address:
  • Phone: 217-521-8703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209011668
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: