Provider Demographics
NPI:1083276042
Name:DERKS-WILSON, EILEEN M (FNP-BC)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:M
Last Name:DERKS-WILSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 N 131ST ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109-3325
Mailing Address - Country:US
Mailing Address - Phone:913-634-9760
Mailing Address - Fax:
Practice Address - Street 1:2450 N 131ST ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66109-3325
Practice Address - Country:US
Practice Address - Phone:913-634-9760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-30
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS78778363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO137300OtherREGISTERED NURSE
KS14-74311-082OtherREGISTEREED NURSE
KS78778OtherADVANCE PRACTICE REGISTERED NURSE