Provider Demographics
NPI:1053632364
Name:MCNARY, DERICK WILLIAM JR (LPN)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:WILLIAM
Last Name:MCNARY
Suffix:JR
Gender:M
Credentials:LPN
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 14794
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-0794
Mailing Address - Country:US
Mailing Address - Phone:216-773-9969
Mailing Address - Fax:
Practice Address - Street 1:10955 SHAKER BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3724
Practice Address - Country:US
Practice Address - Phone:216-773-9969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.130708-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse