Provider Demographics
NPI:1548924590
Name:DILLOW, DERRICK (FNP-C)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:DILLOW
Suffix:
Gender:M
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:PO BOX 843022
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3022
Mailing Address - Country:US
Mailing Address - Phone:317-770-6900
Mailing Address - Fax:317-770-6911
Practice Address - Street 1:14540 PRAIRIE LAKES BLVD N STE 102
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-4370
Practice Address - Country:US
Practice Address - Phone:317-770-9253
Practice Address - Fax:317-770-0134
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71015705A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300096299Medicaid