Provider Demographics
NPI:1962986299
Name:DERTHICK, KATIA (CNM)
Entity type:Individual
Prefix:MS
First Name:KATIA
Middle Name:
Last Name:DERTHICK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:394 LINCOLN PL APT C3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-5819
Mailing Address - Country:US
Mailing Address - Phone:828-545-0395
Mailing Address - Fax:
Practice Address - Street 1:726 BROADWAY FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9616
Practice Address - Country:US
Practice Address - Phone:212-443-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCNM05134367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife