Provider Demographics
NPI:1194749812
Name:DERKSEN, MARY M (CNS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:DERKSEN
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12265 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8613
Mailing Address - Country:US
Mailing Address - Phone:616-494-5453
Mailing Address - Fax:
Practice Address - Street 1:12265 JAMES ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8613
Practice Address - Country:US
Practice Address - Phone:616-494-5453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704158809363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G06004058Medicare ID - Type UnspecifiedMEDICARE NUMBER