Provider Demographics
NPI:1245645811
Name:EVERETT, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:EVERETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3719 MIDDLEBRANCH AVE NE
Mailing Address - Street 2:0
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-5021
Mailing Address - Country:US
Mailing Address - Phone:330-327-0965
Mailing Address - Fax:
Practice Address - Street 1:3719 MIDDLEBRANCH AVE NE
Practice Address - Street 2:0
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-5021
Practice Address - Country:US
Practice Address - Phone:330-327-0965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0093085Medicaid