Healthcare Provider Details

I. General information

NPI: 1053800243
Provider Name (Legal Business Name): DERA JOY HARVEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9333 E 21ST ST N
WICHITA KS
67206-2927
US

IV. Provider business mailing address

1901 E 1ST ST; PO BOX 467
NEWTON KS
67114-0467
US

V. Phone/Fax

Practice location:
  • Phone: 316-634-4700
  • Fax: 316-634-4770
Mailing address:
  • Phone: 316-284-6400
  • Fax: 316-284-6490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number13-116112-082
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number53-78225-082
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: