Provider Demographics
NPI:1669470951
Name:DERRICK, LAUREN C (NP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:C
Last Name:DERRICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 TOWNE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1331
Mailing Address - Country:US
Mailing Address - Phone:315-663-0500
Mailing Address - Fax:315-663-0514
Practice Address - Street 1:5112 W TAFT RD STE J
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-4866
Practice Address - Country:US
Practice Address - Phone:315-701-2170
Practice Address - Fax:315-701-2185
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301621363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01980230Medicaid
P00683943Medicare PIN
NYRA4481Medicare ID - Type Unspecified
RB7333Medicare PIN
CA8940Medicare PIN
NY01980230Medicaid