Provider Demographics
NPI:1245591528
Name:DERR, NANCY W (RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:W
Last Name:DERR
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 SURREY LN
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-9199
Mailing Address - Country:US
Mailing Address - Phone:478-299-0177
Mailing Address - Fax:
Practice Address - Street 1:259 SURREY LN
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-9199
Practice Address - Country:US
Practice Address - Phone:478-299-0177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN120742163WL0100X
174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No174N00000XOther Service ProvidersLactation Consultant, Non-RN