Provider Demographics
NPI:1528271343
Name:DERRYBERRY, ANNALISA KATHLEEN
Entity type:Individual
Prefix:
First Name:ANNALISA
Middle Name:KATHLEEN
Last Name:DERRYBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SW 16TH AVE
Mailing Address - Street 2:APT 92
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-8465
Mailing Address - Country:US
Mailing Address - Phone:352-371-4968
Mailing Address - Fax:
Practice Address - Street 1:5021 NW 34TH ST STE C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-1191
Practice Address - Country:US
Practice Address - Phone:352-377-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA43061225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC4130OtherBCBSF PROVIDER