=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669929386
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERRICK BAILEY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2016
-----------------------------------------------------
Last Update Date | 08/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36 MEDICAL GROUP
-----------------------------------------------------
City | ANDERSEN AFB
-----------------------------------------------------
State | GU
-----------------------------------------------------
Zip | 96543-4010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 671-366-3231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 MEDICAL GROUP UNIT 14010 ANDERSEN AFB
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AP
-----------------------------------------------------
Zip | 96543-4010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 671-366-3231
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN 9369759
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11003419
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------