Provider Demographics
NPI:1619602570
Name:DEDERICK, ELIZABETH ANNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:DEDERICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3952
Mailing Address - Street 2:
Mailing Address - City:LANDERS
Mailing Address - State:CA
Mailing Address - Zip Code:92285-0952
Mailing Address - Country:US
Mailing Address - Phone:760-861-0368
Mailing Address - Fax:
Practice Address - Street 1:1150 N INDIAN CANYON DR
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4872
Practice Address - Country:US
Practice Address - Phone:760-323-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-23
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020328363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily