Provider Demographics
NPI:1720476757
Name:DERENZIS, NICHOLAS JAMES
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAMES
Last Name:DERENZIS
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 1:5193 WADDLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:BLAND
Mailing Address - State:VA
Mailing Address - Zip Code:24315-4710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 S INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:VA
Practice Address - Zip Code:24348
Practice Address - Country:US
Practice Address - Phone:276-773-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205303225100000X
WVPT003561225100000X
WAPT 60386876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist