Provider Demographics
NPI:1417292400
Name:VANSICKLEN, DERRY (HAS)
Entity Type:Individual
Prefix:MR
First Name:DERRY
Middle Name:
Last Name:VANSICKLEN
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 N US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-3196
Mailing Address - Country:US
Mailing Address - Phone:352-751-5860
Mailing Address - Fax:
Practice Address - Street 1:755 N US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-3196
Practice Address - Country:US
Practice Address - Phone:352-751-5860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS 4085237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist