Provider Demographics
NPI:1619571726
Name:DERIT, GLENN HERNANDEZ (APRN)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:HERNANDEZ
Last Name:DERIT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 NICOLLETT WAY
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-2945
Mailing Address - Country:US
Mailing Address - Phone:352-360-8635
Mailing Address - Fax:
Practice Address - Street 1:2201 NICOLLETT WAY
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-2945
Practice Address - Country:US
Practice Address - Phone:352-360-8635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010307363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily