Provider Demographics
NPI:1669847497
Name:EDMOND, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:EDMOND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 ULLOA ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-6942
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3901 ULLOA ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119
Practice Address - Country:US
Practice Address - Phone:504-267-5712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator