Provider Demographics
NPI:1205848009
Name:DEROSA, NANCY DIANE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:DIANE
Last Name:DEROSA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 WOOLDRIDGE FERRY RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-6136
Mailing Address - Country:US
Mailing Address - Phone:270-737-4832
Mailing Address - Fax:
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4590P363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health