Provider Demographics
NPI:1144203019
Name:DERR, VIVIAN (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:
Last Name:DERR
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11448 SANDSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-2522
Mailing Address - Country:US
Mailing Address - Phone:714-839-4553
Mailing Address - Fax:
Practice Address - Street 1:11448 SANDSTONE AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-2522
Practice Address - Country:US
Practice Address - Phone:714-839-4553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW176222363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics