Provider Demographics
NPI:1609947431
Name:DERLACKI, MARY K (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:DERLACKI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0706
Mailing Address - Country:US
Mailing Address - Phone:541-232-6732
Mailing Address - Fax:
Practice Address - Street 1:2800 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3038
Practice Address - Country:US
Practice Address - Phone:208-801-1414
Practice Address - Fax:208-207-2866
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID69483363LF0000X
OR090006104N1207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005785Medicaid
OR005785Medicaid