Provider Demographics
NPI:1104678226
Name:DERYCKE, KRISTI ANN
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:ANN
Last Name:DERYCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7834 11TH AVENUE TRL
Mailing Address - Street 2:
Mailing Address - City:BELLE PLAINE
Mailing Address - State:IA
Mailing Address - Zip Code:52208-8830
Mailing Address - Country:US
Mailing Address - Phone:319-573-5268
Mailing Address - Fax:
Practice Address - Street 1:3245 WILLIAMS PKWY SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-1446
Practice Address - Country:US
Practice Address - Phone:319-369-8820
Practice Address - Fax:319-368-5866
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01018225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist