Provider Demographics
NPI:1104691153
Name:DERRICKSON, SUSAN KAY (NP-BC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:DERRICKSON
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 MAPLEHURST AVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-7006
Mailing Address - Country:US
Mailing Address - Phone:574-302-1640
Mailing Address - Fax:
Practice Address - Street 1:213 MIDDLEBURY ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-2956
Practice Address - Country:US
Practice Address - Phone:574-534-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014637A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine