Provider Demographics
NPI:1730410838
Name:DERRICK, DANA M (DC)
Entity type:Individual
Prefix:DR
First Name:DANA
Middle Name:M
Last Name:DERRICK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6508 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-2045
Mailing Address - Country:US
Mailing Address - Phone:414-328-1734
Mailing Address - Fax:414-328-3166
Practice Address - Street 1:6508 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53219-2045
Practice Address - Country:US
Practice Address - Phone:414-328-1734
Practice Address - Fax:414-328-3166
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4546-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI2798001OtherMEDICARE PTAN