Provider Demographics
NPI:1700669850
Name:DERICHO, AUDREY ELAINE
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:ELAINE
Last Name:DERICHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10905 SW 214TH ST APT 102
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33189-3093
Mailing Address - Country:US
Mailing Address - Phone:786-205-5491
Mailing Address - Fax:
Practice Address - Street 1:15131 TYLER ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-7644
Practice Address - Country:US
Practice Address - Phone:786-205-5491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians