Provider Demographics
NPI:1609155423
Name:DEREVNUK, ALEXANDRA (FNP)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:DEREVNUK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 MADISON AVE
Mailing Address - Street 2:L2-92
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6514
Mailing Address - Country:US
Mailing Address - Phone:212-659-9450
Mailing Address - Fax:212-987-4006
Practice Address - Street 1:17 E 102ND ST
Practice Address - Street 2:2ND FLOOR EHS
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-5204
Practice Address - Country:US
Practice Address - Phone:212-824-7690
Practice Address - Fax:212-426-7704
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332437363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health