Provider Demographics
NPI:1942766241
Name:SIDELL, DERIK W (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:DERIK
Middle Name:W
Last Name:SIDELL
Suffix:
Gender:M
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 STATE RD STE 8
Mailing Address - Street 2:
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-9141
Mailing Address - Country:US
Mailing Address - Phone:440-967-8713
Mailing Address - Fax:440-967-1938
Practice Address - Street 1:1605 STATE RD STE 8
Practice Address - Street 2:
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089-9141
Practice Address - Country:US
Practice Address - Phone:440-967-8713
Practice Address - Fax:440-967-1938
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.024223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0335493Medicaid