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General NPI Number Information
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NPI Number | 1396282448
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Entity Type | Individual
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Provider Name | DEREK STORCK FNP-BC
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Gender | Male
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Dates
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Enumeration Date | 01/27/2017
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Last Update Date | 11/27/2019
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Provider Practice Location Address
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Address Line | 42348 MALBECK DR
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City | STERLING HEIGHTS
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State | MI
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Zip | 48314-3043
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Country | US
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Telephone | 618-910-0465
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Fax |
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Provider Business Mailing Address
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Address Line | 929 STACEY BURK DR
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City | FLORA
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State | IL
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Zip | 62839-3241
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Country | US
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Telephone | 618-910-0465
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 4704322025
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 209016175
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License Number State | IL
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