Provider Demographics
NPI:1396282448
Name:STORCK, DEREK (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:DEREK
Middle Name:
Last Name:STORCK
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 STACEY BURK DR
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-3241
Mailing Address - Country:US
Mailing Address - Phone:618-910-0465
Mailing Address - Fax:
Practice Address - Street 1:42348 MALBECK DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-3043
Practice Address - Country:US
Practice Address - Phone:618-910-0465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704322025363LF0000X
IL209016175363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty