Provider Demographics
NPI:1245581974
Name:DERRICO, MARY ANNE (APRN-CNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:DERRICO
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13631 NE TOWNLEY RD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:OK
Mailing Address - Zip Code:73538-3705
Mailing Address - Country:US
Mailing Address - Phone:580-512-0746
Mailing Address - Fax:580-250-0506
Practice Address - Street 1:13631 NE TOWNLEY RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:OK
Practice Address - Zip Code:73538-3705
Practice Address - Country:US
Practice Address - Phone:580-512-0746
Practice Address - Fax:580-250-0506
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-20
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK49043363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK45113OtherOKLAHOMA STATE BUREAU OF NARCOTICS AND DANGEROUS DRUG CONTROL REGISTRATION NUMBE