Provider Demographics
NPI:1417441718
Name:DERVISEVIC, ANITA (FNP)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:DERVISEVIC
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-3210
Mailing Address - Country:US
Mailing Address - Phone:315-939-0214
Mailing Address - Fax:
Practice Address - Street 1:3136 ONEIDA ST
Practice Address - Street 2:
Practice Address - City:SAUQUOIT
Practice Address - State:NY
Practice Address - Zip Code:13456-2800
Practice Address - Country:US
Practice Address - Phone:315-737-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343098363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty