Healthcare Provider Details

I. General information

NPI: 1750037560
Provider Name (Legal Business Name): DERRICK MARPLE MSN-FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 E HOME RD
SPRINGFIELD OH
45503-2725
US

IV. Provider business mailing address

931 WILSON RD
SOUTH VIENNA OH
45369-9747
US

V. Phone/Fax

Practice location:
  • Phone: 937-342-1619
  • Fax: 937-390-7148
Mailing address:
  • Phone: 937-605-9294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0030729
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: