Provider Demographics
NPI:1306554068
Name:DEROLUS, ANIE SOPHIA (MSN, FNP-BC)
Entity type:Individual
Prefix:
First Name:ANIE
Middle Name:SOPHIA
Last Name:DEROLUS
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 WOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-3857
Mailing Address - Country:US
Mailing Address - Phone:617-953-6617
Mailing Address - Fax:
Practice Address - Street 1:152 WOOD AVE
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3857
Practice Address - Country:US
Practice Address - Phone:617-953-6617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-11
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2348277163WP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health