Healthcare Provider Details

I. General information

NPI: 1871962167
Provider Name (Legal Business Name): BARBARA JEAN DERRICO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 NE LAWRIE TATUM RD
LAWTON OK
73507-3002
US

IV. Provider business mailing address

1515 NE LAWRIE TATUM RD
LAWTON OK
73507-3002
US

V. Phone/Fax

Practice location:
  • Phone: 580-354-5454
  • Fax: 580-354-5212
Mailing address:
  • Phone: 580-354-5454
  • Fax: 580-354-5212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0600X
TaxonomyInfection Control Registered Nurse
License Number39063
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: