Provider Demographics
NPI:1780308288
Name:DERRICKSON, ARIELLA JUANITA
Entity type:Individual
Prefix:MS
First Name:ARIELLA
Middle Name:JUANITA
Last Name:DERRICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 GILLAM WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-6043
Mailing Address - Country:US
Mailing Address - Phone:907-451-6682
Mailing Address - Fax:
Practice Address - Street 1:1427 GILLAM WAY
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-6043
Practice Address - Country:US
Practice Address - Phone:907-451-6682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK0000000000000Medicaid