Provider Demographics
NPI:1386965754
Name:DERLA, JOSE MARIE CORNELIO (RN)
Entity type:Individual
Prefix:
First Name:JOSE MARIE
Middle Name:CORNELIO
Last Name:DERLA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MICHAEL AVE
Mailing Address - Street 2:
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-9224
Mailing Address - Country:US
Mailing Address - Phone:224-353-9424
Mailing Address - Fax:
Practice Address - Street 1:2400 MICHAEL AVE
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-9224
Practice Address - Country:US
Practice Address - Phone:224-353-9424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.359360163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health