Provider Demographics
NPI:1164421806
Name:DERRICK, DAVA J (CNP)
Entity Type:Individual
Prefix:
First Name:DAVA
Middle Name:J
Last Name:DERRICK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 NATIONAL RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CLAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45315-9505
Mailing Address - Country:US
Mailing Address - Phone:937-836-5165
Mailing Address - Fax:937-836-6709
Practice Address - Street 1:1250 NATIONAL RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CLAYTON
Practice Address - State:OH
Practice Address - Zip Code:45315-9505
Practice Address - Country:US
Practice Address - Phone:937-836-5165
Practice Address - Fax:937-836-6709
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP06888363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2372418Medicaid
OHP00186293OtherRR MEDICARE
OH000000292814OtherANTHEM
OHP00186293OtherRR MEDICARE
OHP59657Medicare UPIN