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General NPI Number Information
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NPI Number | 1609947431
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Entity Type | Individual
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Provider Name | MARY K DERLACKI FNP
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Gender | Female
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | 2800 W OVERLAND RD
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City | BOISE
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State | ID
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Zip | 83705-3038
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Country | US
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Telephone | 208-801-1414
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Fax | 208-207-2866
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Provider Business Mailing Address
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Address Line | 1707 N 19TH ST
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City | BOISE
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State | ID
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Zip | 83702-0706
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Country | US
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Telephone | 541-232-6732
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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 | 69483
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 090006104N1
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License Number State | OR
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