Provider Demographics
NPI:1558733485
Name:DERRYBERRY, TRACY (RN)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:
Last Name:DERRYBERRY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10110 BAHAMA DR
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-1506
Mailing Address - Country:US
Mailing Address - Phone:305-577-4840
Mailing Address - Fax:305-400-6243
Practice Address - Street 1:10110 BAHAMA DR
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-1506
Practice Address - Country:US
Practice Address - Phone:305-577-4840
Practice Address - Fax:305-400-6243
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9417391163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN9417391OtherRN LICENSE