Provider Demographics
NPI:1548748858
Name:DERIDDER, MARILYN M (APRN)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:M
Last Name:DERIDDER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 S WEIR CANYON RD STE 328
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92808-1962
Mailing Address - Country:US
Mailing Address - Phone:714-280-1495
Mailing Address - Fax:
Practice Address - Street 1:1211 W LA PALMA AVE STE 404
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2806
Practice Address - Country:US
Practice Address - Phone:714-772-8282
Practice Address - Fax:714-772-6493
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-30
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMD5036175363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty