Healthcare Provider Details

I. General information

NPI: 1982463584
Provider Name (Legal Business Name): ELIZABETH DEDERICK, NURSING, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60547 STAGEMANS RD
LANDERS CA
92285-9402
US

IV. Provider business mailing address

PO BOX 3952
LANDERS CA
92285-0952
US

V. Phone/Fax

Practice location:
  • Phone: 760-861-0368
  • Fax: 760-273-0921
Mailing address:
  • Phone: 760-910-1112
  • Fax: 760-273-0921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH ANNE DEDERICK
Title or Position: CEO
Credential: FNP
Phone: 760-910-1112