Provider Demographics
NPI:1588927453
Name:AYCOCK, DEIRDRE M (CRNP)
Entity type:Individual
Prefix:MRS
First Name:DEIRDRE
Middle Name:M
Last Name:AYCOCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 294
Mailing Address - Street 2:
Mailing Address - City:PINE HILL
Mailing Address - State:AL
Mailing Address - Zip Code:36769-0294
Mailing Address - Country:US
Mailing Address - Phone:334-963-2113
Mailing Address - Fax:334-963-2116
Practice Address - Street 1:45 INDUSTRIAL DR W
Practice Address - Street 2:
Practice Address - City:PINE HILL
Practice Address - State:AL
Practice Address - Zip Code:36769-3369
Practice Address - Country:US
Practice Address - Phone:334-963-2113
Practice Address - Fax:334-963-2116
Is Sole Proprietor?:No
Enumeration Date:2012-06-16
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-053747363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL180596Medicaid