Healthcare Provider Details

I. General information

NPI: 1740193796
Provider Name (Legal Business Name): DEIDRA MARIAH DERRICO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 BALBOA BLVD STE 326
ENCINO CA
91316-5214
US

IV. Provider business mailing address

5400 BALBOA BLVD STE 326
ENCINO CA
91316-5214
US

V. Phone/Fax

Practice location:
  • Phone: 818-789-0941
  • Fax: 818-789-6726
Mailing address:
  • Phone: 818-789-0941
  • Fax: 818-789-6726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number95395937
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: