Individual
MS. SUSAN M DERIVAS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CNP
Contact information
Practice address
4055 E BLUEBERRY ST, MERIDIAN, ID 83642-8261
(208) 775-7418
(208) 647-5008
Mailing address
4055 E BLUEBERRY ST, MERIDIAN, ID 83642-8261
(208) 775-7418
(208) 674-5008
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
64266
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0062-0104069
UNITED HEALTHCARE SERVICES, PROVIDER NO.
—
05
—
1032026
—
ID
01
—
13961493
CAQH PROVIDER ID
—
01
—
1851493829
CLOZAPINE REMS CERTIFIED
—
01
—
208-775-7418
SPRUCE HEALTH
—
01
—
396453
MASTER BILLING ID (OSMIND)
—
01
—
5708247
EVERNORTH
ID
01
—
909072
CHANGE HEALTHCARE SUBMITTER ID
—
01
—
932434
AVAILITY ID
—
Enumeration date
09/01/2006
Last updated
02/07/2024
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