Provider Demographics
NPI:1356080618
Name:PRICE, DERRIYAN LANAE (DO)
Entity type:Individual
Prefix:
First Name:DERRIYAN
Middle Name:LANAE
Last Name:PRICE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 MARVIN SHIELDS BLVD,
Mailing Address - Street 2:BLDG 472
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501
Mailing Address - Country:US
Mailing Address - Phone:228-822-5061
Mailing Address - Fax:228-871-3390
Practice Address - Street 1:5502 MARVIN SHIELDS BLVD
Practice Address - Street 2:BLDG 472
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-822-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102208259390200000X, 207Q00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171000000XOther Service ProvidersMilitary Health Care Provider