Provider Demographics
NPI:1427407832
Name:DERRICK, MELISSA (RN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
Credentials:RN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 HIGHWAY 104
Mailing Address - Street 2:
Mailing Address - City:IONE
Mailing Address - State:CA
Mailing Address - Zip Code:95640
Mailing Address - Country:US
Mailing Address - Phone:805-206-5510
Mailing Address - Fax:
Practice Address - Street 1:4001 HIGHWAY 104
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640
Practice Address - Country:US
Practice Address - Phone:805-206-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23576363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health