Provider Demographics
NPI:1124169107
Name:DERZAY, TERESE ANGELA (LMP)
Entity type:Individual
Prefix:MISS
First Name:TERESE
Middle Name:ANGELA
Last Name:DERZAY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16544
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-0544
Mailing Address - Country:US
Mailing Address - Phone:206-852-1555
Mailing Address - Fax:
Practice Address - Street 1:2715 CALIFORNIA AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-2469
Practice Address - Country:US
Practice Address - Phone:206-852-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA14332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist