Healthcare Provider Details

I. General information

NPI: 1275447286
Provider Name (Legal Business Name): CHRISTA DEDERICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 2ND ST
WATERFORD NY
12188-2417
US

IV. Provider business mailing address

84 2ND ST
WATERFORD NY
12188-2417
US

V. Phone/Fax

Practice location:
  • Phone: 518-785-5511
  • Fax:
Mailing address:
  • Phone: 518-785-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number614457
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: