Provider Demographics
NPI:1356770028
Name:DERBY, MICHELLE (LAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DERBY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:42101 N 41ST DR STE C-152
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3816
Mailing Address - Country:US
Mailing Address - Phone:602-478-4004
Mailing Address - Fax:602-374-3123
Practice Address - Street 1:42101 N 41ST DR STE C-152
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3816
Practice Address - Country:US
Practice Address - Phone:602-478-4004
Practice Address - Fax:602-483-1662
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ547171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist