Healthcare Provider Details

I. General information

NPI: 1922333194
Provider Name (Legal Business Name): DERRICK LANE WILLIAMS RN, APRN, ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2009
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

10351 DAWSONS CREEK BLVD SUITE A-1
FORT WAYNE IN
46825-1904
US

V. Phone/Fax

Practice location:
  • Phone: 260-203-9600
  • Fax: 260-739-6167
Mailing address:
  • Phone: 260-203-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number28139511A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71003104A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: