Individual
MARY K DERLACKI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
2800 W OVERLAND RD, BOISE, ID 83705-3038
(208) 801-1414
(208) 207-2866
Mailing address
1707 N 19TH ST, BOISE, ID 83702-0706
(541) 232-6732
Taxonomy
Speciality
Code
Description
License number
State
207RR0500X
Rheumatology Physician
Primary
090006104N1
OR
363LF0000X
Family Nurse Practitioner
69483
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
005785
—
OR
Enumeration date
11/13/2006
Last updated
10/17/2024
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