Provider Demographics
NPI:1144867243
Name:DERRERA, STACY C (NP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:C
Last Name:DERRERA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 W 44TH AVE
Mailing Address - Street 2:UNIT 200
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2742
Mailing Address - Country:US
Mailing Address - Phone:303-993-1330
Mailing Address - Fax:303-284-4082
Practice Address - Street 1:309 RUSHMORE ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:CO
Practice Address - Zip Code:80107-7928
Practice Address - Country:US
Practice Address - Phone:970-619-9084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-08
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0995141-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner