Provider Demographics
NPI:1902877459
Name:DERRICK, KATHRYN LOUISE (RN)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:LOUISE
Last Name:DERRICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:DERRICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:8114 S 2470 W
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-7662
Mailing Address - Country:US
Mailing Address - Phone:801-233-0518
Mailing Address - Fax:
Practice Address - Street 1:4460 HIGHLAND DR
Practice Address - Street 2:#300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3543
Practice Address - Country:US
Practice Address - Phone:801-273-6326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3141673102163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management