Provider Demographics
NPI:1225755119
Name:DERICK SALLE, NDENE (DNP, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:NDENE
Middle Name:
Last Name:DERICK SALLE
Suffix:
Gender:M
Credentials:DNP, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9550 S VIA BANDERA
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-2167
Mailing Address - Country:US
Mailing Address - Phone:240-425-7240
Mailing Address - Fax:
Practice Address - Street 1:10000 S WILMOT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85756-8699
Practice Address - Country:US
Practice Address - Phone:240-425-7240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ256335363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health