1356080618 NPI number — DERRIYAN LANAE PRICE DO

Table of content: DERRIYAN LANAE PRICE DO (NPI 1356080618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356080618 NPI number — DERRIYAN LANAE PRICE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRICE
Provider First Name:
DERRIYAN
Provider Middle Name:
LANAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356080618
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5502 MARVIN SHIELDS BLVD,
Provider Second Line Business Mailing Address:
BLDG 472
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-822-5061
Provider Business Mailing Address Fax Number:
228-871-3390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5502 MARVIN SHIELDS BLVD
Provider Second Line Business Practice Location Address:
BLDG 472
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-822-5061
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/03/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , with the licence number:  0102208259 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 0102208259 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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