Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | DH068197 | PA |
N | 124Q00000X | Dental Hygienist | PHDH000337 | PA |
NPI | 1033621503 |
---|---|
Provider Name | Carrie Michele Derk |
First Address | Chambersburg, PA 17201-4207 |
Second Address | Chambersburg, PA 17201-4207 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2017 |
Last Update Date | 24/10/2017 |