Basic Information
| Provider Information | |||||||||
| NPI: | 1891237814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAILEY | ||||||||
| FirstName: | DERRICK | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | FNP, AGACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 E 16TH AVE | ||||||||
| Address2: | |||||||||
| City: | CORDELE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310151514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292738881 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3131 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919021 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2016 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | RN209392 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LF0000X | RN209392 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | RN209392 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.