Provider Demographics
NPI:1508266842
Name:DERIVAL, SANDIE JEAN (APRN)
Entity Type:Individual
Prefix:
First Name:SANDIE
Middle Name:JEAN
Last Name:DERIVAL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SANDIE
Other - Middle Name:
Other - Last Name:JEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:20 YORK STREET, CB-2041
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-4748
Mailing Address - Fax:203-688-4740
Practice Address - Street 1:20 YORK STREET, CB-2041
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510
Practice Address - Country:US
Practice Address - Phone:203-688-4748
Practice Address - Fax:203-688-4740
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5821363LF0000X
CT005821363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily