Provider Demographics
NPI:1134586209
Name:DERRICK, KRISTEEN
Entity type:Individual
Prefix:
First Name:KRISTEEN
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17360 BROOKHURST ST
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2865 ATLANTIC AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1740
Practice Address - Country:US
Practice Address - Phone:562-988-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant