Provider Demographics
NPI:1336508886
Name:DERHAGOPIAN, ALEXIS LORI (NP)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:LORI
Last Name:DERHAGOPIAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:LORI
Other - Last Name:MALLOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:333 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3936
Mailing Address - Country:US
Mailing Address - Phone:609-781-4116
Mailing Address - Fax:
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-6923
Practice Address - Fax:609-291-5507
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR16041100163W00000X
NY343863363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse