Provider Demographics
NPI:1912472242
Name:DERKOWSKI, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DERKOWSKI
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 1:2255 W PERSHING ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-6061
Mailing Address - Country:US
Mailing Address - Phone:920-509-2025
Mailing Address - Fax:
Practice Address - Street 1:2255 W PERSHING ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-6061
Practice Address - Country:US
Practice Address - Phone:920-509-2025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-13
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI323307164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse