Healthcare Provider Details

I. General information

NPI: 1669470951
Provider Name (Legal Business Name): LAUREN C DERRICK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5112 W TAFT RD STE J
LIVERPOOL NY
13088-4866
US

IV. Provider business mailing address

510 TOWNE DR
FAYETTEVILLE NY
13066-1331
US

V. Phone/Fax

Practice location:
  • Phone: 315-701-2170
  • Fax: 315-701-2185
Mailing address:
  • Phone: 315-663-0500
  • Fax: 315-663-0514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number301621
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: