Provider Demographics
NPI:1306116736
Name:DERRICK, ALYSSA KAYLE (LMP)
Entity type:Individual
Prefix:MISS
First Name:ALYSSA
Middle Name:KAYLE
Last Name:DERRICK
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 1:5521 186TH PL SW
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-4325
Mailing Address - Country:US
Mailing Address - Phone:425-776-3000
Mailing Address - Fax:
Practice Address - Street 1:4803 84TH ST SW
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-3023
Practice Address - Country:US
Practice Address - Phone:425-290-6024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-02
Last Update Date:2012-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60253192174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60253192OtherL.M.P.