Healthcare Provider Details

I. General information

NPI: 1730266065
Provider Name (Legal Business Name): SUSAN M DERRICK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 SEAFARERS LN
ROCHESTER NY
14612-2947
US

IV. Provider business mailing address

117 SEAFARERS LN
ROCHESTER NY
14612-2947
US

V. Phone/Fax

Practice location:
  • Phone: 585-723-0713
  • Fax:
Mailing address:
  • Phone: 585-723-0713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number416803-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: