Provider Demographics
NPI:1831743806
Name:DERRICK, ASHLEY (FNP-C)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 WOODRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39827-7328
Mailing Address - Country:US
Mailing Address - Phone:850-879-1298
Mailing Address - Fax:
Practice Address - Street 1:2433 MAHAN DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5329
Practice Address - Country:US
Practice Address - Phone:850-219-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11003463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily