Provider Demographics
NPI:1396219390
Name:DERRICK, ROSETTA ANN (NP)
Entity Type:Individual
Prefix:
First Name:ROSETTA
Middle Name:ANN
Last Name:DERRICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 BEN FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:SC
Mailing Address - Zip Code:29054-9520
Mailing Address - Country:US
Mailing Address - Phone:803-260-4250
Mailing Address - Fax:
Practice Address - Street 1:2258 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4887
Practice Address - Country:US
Practice Address - Phone:706-724-4400
Practice Address - Fax:706-724-6003
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN241900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily