Provider Demographics
NPI:1730266065
Name:DERRICK, SUSAN M (RN)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:DERRICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 SEAFARERS LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-2947
Mailing Address - Country:US
Mailing Address - Phone:585-723-0713
Mailing Address - Fax:
Practice Address - Street 1:117 SEAFARERS LN
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-2947
Practice Address - Country:US
Practice Address - Phone:585-723-0713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY416803-1163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01649229Medicaid