Provider Demographics
NPI:1437839560
Name:DERHAK, ELIZABETH (LPN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:DERHAK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2957
Mailing Address - Country:US
Mailing Address - Phone:207-874-2141
Mailing Address - Fax:
Practice Address - Street 1:934 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3032
Practice Address - Country:US
Practice Address - Phone:207-874-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELPN12298164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse