Provider Demographics
NPI:1922333194
Name:WILLIAMS, DERRICK LANE (RN, APRN, ACNP)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:LANE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:RN, APRN, ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:10351 DAWSONS CREEK BLVD
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1904
Mailing Address - Country:US
Mailing Address - Phone:260-203-9600
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-203-9600
Practice Address - Fax:260-739-6167
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28139511A363LA2100X
IN71003104A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200972030Medicaid
IN200972030Medicaid