Provider Demographics
NPI:1558386912
Name:ANDERSON, DERRYTH L (RN)
Entity Type:Individual
Prefix:
First Name:DERRYTH
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 NAUSAUKET RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-7507
Mailing Address - Country:US
Mailing Address - Phone:401-921-1606
Mailing Address - Fax:
Practice Address - Street 1:55 JOHN A CUMMINGS WAY
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-3247
Practice Address - Country:US
Practice Address - Phone:401-235-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN38206163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDA42457Medicaid