Provider Demographics
NPI:1912194358
Name:CLERVILLE DERATUS, REBECA (FNP)
Entity Type:Individual
Prefix:
First Name:REBECA
Middle Name:
Last Name:CLERVILLE DERATUS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PENN PLAZA 7TH FL STE
Mailing Address - Street 2:EVERCARE UNITED HEALTHCARE
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10119
Mailing Address - Country:US
Mailing Address - Phone:212-216-6568
Mailing Address - Fax:212-216-6606
Practice Address - Street 1:1 PENN PLAZA 7TH FL STE 725
Practice Address - Street 2:EVERCARE UNITED HEALTHCARE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10119
Practice Address - Country:US
Practice Address - Phone:212-216-6568
Practice Address - Fax:212-216-6606
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily