Provider Demographics
NPI:1053509323
Name:DERBY, SHANE (RN)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:DERBY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 MASS AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2318
Mailing Address - Country:US
Mailing Address - Phone:857-654-1000
Mailing Address - Fax:857-654-1100
Practice Address - Street 1:729 MASS AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2318
Practice Address - Country:US
Practice Address - Phone:857-654-1000
Practice Address - Fax:857-654-1100
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263329163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse