Provider Demographics
NPI:1891011433
Name:DERYCKE, CAROL MARIE (RN, BSN)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:MARIE
Last Name:DERYCKE
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 SUNSET TRL
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1922
Mailing Address - Country:US
Mailing Address - Phone:585-753-5163
Mailing Address - Fax:585-753-5188
Practice Address - Street 1:111 WESTFALL RD RM 864
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-4647
Practice Address - Country:US
Practice Address - Phone:585-753-5163
Practice Address - Fax:585-753-5188
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY443882-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse