Provider Demographics
NPI:1851493829
Name:DERIVAS, SUSAN M (CNP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:DERIVAS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
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Mailing Address - Street 1:4055 E BLUEBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8261
Mailing Address - Country:US
Mailing Address - Phone:208-775-7418
Mailing Address - Fax:208-674-5008
Practice Address - Street 1:4055 E BLUEBERRY ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8261
Practice Address - Country:US
Practice Address - Phone:208-775-7418
Practice Address - Fax:208-647-5008
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID64266363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
208-775-7418OtherSPRUCE HEALTH
ID1032026Medicaid
ID5708247OtherEVERNORTH
932434OtherAVAILITY ID
0062-0104069OtherUNITED HEALTHCARE SERVICES, PROVIDER NO.
13961493OtherCAQH PROVIDER ID
909072OtherCHANGE HEALTHCARE SUBMITTER ID
1851493829OtherCLOZAPINE REMS CERTIFIED
396453OtherMASTER BILLING ID (OSMIND)