Basic Information
| Provider Information | |||||||||
| NPI: | 1922386010 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERKSEN | ||||||||
| FirstName: | LEAH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2960 N CIRCLE DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809091163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196348891 | ||||||||
| FaxNumber: | 7196341897 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960 N CIRCLE DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809091163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196348891 | ||||||||
| FaxNumber: | 7196341897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2011 | ||||||||
| LastUpdateDate: | 07/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 990102 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 78270766 | 05 | CO | MEDICAID |