Healthcare Provider Details

I. General information

NPI: 1023925294
Provider Name (Legal Business Name): MR. DERRICK ROBERTS NUTTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

278 WHITES BRIDGE RD STE 1
STANDISH ME
04084-5263
US

IV. Provider business mailing address

14 BEA ST
DOVER FOXCROFT ME
04426-3616
US

V. Phone/Fax

Practice location:
  • Phone: 207-892-6766
  • Fax:
Mailing address:
  • Phone: 207-717-9584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: