Provider Demographics
NPI:1326591595
Name:DERENG, OSAYAMEN
Entity Type:Individual
Prefix:
First Name:OSAYAMEN
Middle Name:
Last Name:DERENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5497 RATHDRUM WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8681
Mailing Address - Country:US
Mailing Address - Phone:510-415-1235
Mailing Address - Fax:
Practice Address - Street 1:5497 RATHDRUM WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8681
Practice Address - Country:US
Practice Address - Phone:510-415-1235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA634659163W00000X
CA95005210363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse