Provider Demographics
NPI:1467813378
Name:DERICKS, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:DERICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 BELMONT AVE E
Mailing Address - Street 2:APT 502
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-4873
Mailing Address - Country:US
Mailing Address - Phone:970-331-2583
Mailing Address - Fax:
Practice Address - Street 1:515 KIRKLAND WAY
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-6219
Practice Address - Country:US
Practice Address - Phone:970-331-2583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-19
Last Update Date:2016-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 60632595171100000X
WANT60614280175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No175F00000XOther Service ProvidersNaturopath