Provider Demographics
NPI:1205809225
Name:DERUCKI, CAROLE ANNE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:CAROLE
Middle Name:ANNE
Last Name:DERUCKI
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MISS
Other - First Name:CAROLE
Other - Middle Name:ANNE
Other - Last Name:BRANCALEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23448 SHURTE ST
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-9738
Mailing Address - Country:US
Mailing Address - Phone:574-993-1158
Mailing Address - Fax:269-408-4346
Practice Address - Street 1:2900 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2379
Practice Address - Country:US
Practice Address - Phone:269-932-7859
Practice Address - Fax:269-932-7859
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002723A174400000X, 363L00000X
MI4704166108363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No174400000XOther Service ProvidersSpecialist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI478536310Medicaid
IN200917690AMedicaid
IN000000723347OtherBCBS
IN200917690Medicaid
MI4704166108OtherMICHIGAN
IN737280IMedicare PIN
MI4704166108OtherMICHIGAN
INQ53345Medicare UPIN
MIQ53345Medicare UPIN
OM44080Medicare PIN