Provider Demographics
NPI:1093235319
Name:DERIVAL, DALINE (RN, MSN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:DALINE
Middle Name:
Last Name:DERIVAL
Suffix:
Gender:F
Credentials:RN, MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:677 E 19TH STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230
Practice Address - Country:US
Practice Address - Phone:404-388-4725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY718612163W00000X
NYF342636-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse