Provider Demographics
NPI:1962613570
Name:DERRICK, DAWN MICHELLE (ARNP)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:MICHELLE
Last Name:DERRICK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 N MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1849
Mailing Address - Country:US
Mailing Address - Phone:407-894-4474
Mailing Address - Fax:407-894-4474
Practice Address - Street 1:1613 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1849
Practice Address - Country:US
Practice Address - Phone:407-894-4474
Practice Address - Fax:407-894-4474
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005842363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-005842OtherIL STATE LIC
FLU0580ZMedicare PIN