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General NPI Number Information
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NPI Number | 1740193796
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Entity Type | Individual
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Provider Name | DEIDRA MARIAH DERRICO
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Gender | Female
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Dates
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Enumeration Date | 09/22/2026
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Last Update Date | 09/22/2026
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Provider Practice Location Address
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Address Line | 5400 BALBOA BLVD STE 326
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City | ENCINO
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State | CA
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Zip | 91316-5214
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Country | US
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Telephone | 818-789-0941
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Fax | 818-789-6726
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Provider Business Mailing Address
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Address Line | 5400 BALBOA BLVD STE 326
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City | ENCINO
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State | CA
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Zip | 91316-5214
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Country | US
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Telephone | 818-789-0941
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Fax | 818-789-6726
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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 | 163WP0200X
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Taxonomy Name | Pediatric Registered Nurse
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License Number | 95395937
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License Number State | CA
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