Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | SP023959 | PA |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | SP023959 | PA |
NPI | 1003487992 |
---|---|
Provider Name | Jonelle R Derk |
First Address | Wormleysburg, PA 17043-1034 |
Second Address | Wormleysburg, PA 17043-1034 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2021 |
Last Update Date | 11/10/2021 |