Provider Demographics
NPI:1811089899
Name:MCCLEERY-DERRICK, SUSEN DEANNE (FNP)
Entity type:Individual
Prefix:
First Name:SUSEN
Middle Name:DEANNE
Last Name:MCCLEERY-DERRICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SUSEN
Other - Middle Name:DEANNE
Other - Last Name:DERRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6065 SPORTS VILLAGE RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-3523
Mailing Address - Country:US
Mailing Address - Phone:214-705-7390
Mailing Address - Fax:214-705-7393
Practice Address - Street 1:6065 SPORTS VILLAGE RD
Practice Address - Street 2:SUITE 600
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-3523
Practice Address - Country:US
Practice Address - Phone:214-705-7390
Practice Address - Fax:214-705-7393
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128464363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1568073Medicaid
TX1568073Medicaid
TX1568073Medicaid