Provider Demographics
NPI:1871105320
Name:DERRICK, KIWANA N (RN, AGNP-C)
Entity type:Individual
Prefix:MRS
First Name:KIWANA
Middle Name:N
Last Name:DERRICK
Suffix:
Gender:F
Credentials:RN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2182
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091-1182
Mailing Address - Country:US
Mailing Address - Phone:931-652-2521
Mailing Address - Fax:
Practice Address - Street 1:529 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-3219
Practice Address - Country:US
Practice Address - Phone:931-270-9729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN196202163WG0600X
TNAPN0000028011363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0600XNursing Service ProvidersRegistered NurseGerontology