Provider Demographics
NPI:1568059145
Name:NYE, DEREK RUSSELL (RN, PHN)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:RUSSELL
Last Name:NYE
Suffix:
Gender:M
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3317 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-6614
Mailing Address - Country:US
Mailing Address - Phone:619-201-0881
Mailing Address - Fax:
Practice Address - Street 1:3851 ROSECRANS ST STE 716
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3115
Practice Address - Country:US
Practice Address - Phone:619-972-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95206866163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse