Individual
MRS. CAROLE ANNE DERUCKI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP-BC
Contact information
Practice address
2900 LAKEVIEW AVE, SAINT JOSEPH, MI 49085-2379
(269) 932-7859
(269) 932-7859
Mailing address
23448 SHURTE ST, CASSOPOLIS, MI 49031-9738
(574) 993-1158
(269) 408-4346
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
71002723A
IN
363L00000X
Nurse Practitioner
4704166108
MI
363L00000X
Nurse Practitioner
71002723A
IN
363LF0000X
Family Nurse Practitioner
Primary
4704166108
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000723347
BCBS
IN
05
—
200917690
—
IN
05
—
200917690A
—
IN
01
—
4704166108
MICHIGAN
MI
05
—
478536310
—
MI
Enumeration date
02/09/2006
Last updated
02/29/2024
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