Healthcare Provider Details

I. General information

NPI: 1063985521
Provider Name (Legal Business Name): DEREK ROBERT FREE ACNPC-AG, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 KEMPSVILLE RD STE 212
NORFOLK VA
23502-3927
US

IV. Provider business mailing address

844 KEMPSVILLE RD STE 212
NORFOLK VA
23502-3927
US

V. Phone/Fax

Practice location:
  • Phone: 757-261-5977
  • Fax: 757-275-9913
Mailing address:
  • Phone: 757-261-5977
  • Fax: 757-275-9913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5011226
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCNP.026029
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024176978
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: