Provider Demographics
NPI:1386639144
Name:DERRICO, JUDITH ANNE (CRNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANNE
Last Name:DERRICO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ANNE
Other - Last Name:FLYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:46440 BENEDICT DR
Mailing Address - Street 2:STE 208
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-6602
Mailing Address - Country:US
Mailing Address - Phone:703-444-3660
Mailing Address - Fax:703-444-3569
Practice Address - Street 1:46440 BENEDICT DR
Practice Address - Street 2:STE 208
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-6602
Practice Address - Country:US
Practice Address - Phone:703-444-3660
Practice Address - Fax:703-444-3569
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024092254363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
S59547Medicare UPIN
VA007973L19Medicare ID - Type Unspecified