Provider Demographics
NPI:1083880645
Name:DERBY, SUSAN ANN (MA GNP-BC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ANN
Last Name:DERBY
Suffix:
Gender:F
Credentials:MA GNP-BC
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Mailing Address - Street 1:1275 YORK AVE
Mailing Address - Street 2:MEMORIAL SLOAN-KETTERING CANCER CENTER BOX 52
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6007
Mailing Address - Country:US
Mailing Address - Phone:646-888-2723
Mailing Address - Fax:646-888-2735
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:MEMORIAL SLOAN KETTERING CANCER CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:646-888-2723
Practice Address - Fax:646-888-2735
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY340138363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology