Provider Demographics
NPI:1831913920
Name:DERRY, ALEXANDRIA LORRAINE
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:LORRAINE
Last Name:DERRY
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:PO BOX 784
Mailing Address - Street 2:
Mailing Address - City:BLUE JAY
Mailing Address - State:CA
Mailing Address - Zip Code:92317-0784
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26571CA-18
Practice Address - Street 2:
Practice Address - City:RIMFOREST
Practice Address - State:CA
Practice Address - Zip Code:92378
Practice Address - Country:US
Practice Address - Phone:909-337-4192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant