NPIMap

Individual provider Active NPI

Kristen Alice Derderian, CNP

  • Primary Care Nurse Practitioner
  • Saint Louis, MO
National Provider Identifier
1407417645
Registry record updated Mar 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Nurse PractitionerTaxonomy code 363LP2300X
License
2021013574 Issued in MO
Practice address
12200 Weber Hill Rd Ste 100
Saint Louis, MO 63127-1599
Phone
(314) 698-2500
Fax
(314) 698-2323
NPI assigned
Jun 27, 2019
Last updated
Mar 21, 2022By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 21, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Nurse Practitioner 363LP2300X RN2321686 MA
Primary Care Nurse Practitioner 363LP2300X 2021013574 MO Primary

Addresses

Primary practice location

12200 Weber Hill Rd Ste 100
Saint Louis, MO 63127-1599

Mailing address

12200 Weber Hill Rd Ste 100
Saint Louis, MO 63127-1599
Phone (314) 698-2500

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20191219000953 MA Practitioner - Nurse Practitioner 8022442326 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

100 Brigham Way
Westwood, MA 02090-2445
Phone (877) 937-8128

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Certified Nurse Practitioner, Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
RN2321686MAMDPrimary Care Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Brigham and Women's Hospital Current Accepting new patients
Mass General Brigham Community Physicians Inc. Family Medicine CurrentSince Oct 1, 2024 Accepting new patients
Revere Medical of Massachusetts, PC Family Medicine CurrentSince Oct 30, 2024 Accepting new patients
Steward Medical Group, Inc CurrentSince Dec 1, 2019 Accepting new patients
Mass General Brigham Community Physicians Inc CurrentSince Oct 1, 2024 Accepting new patients
Steward Medical Group, Inc CurrentSince Dec 1, 2019 Accepting new patients
Mass General Brigham Community Physicians Inc. Past Accepting new patients

Locations

11 Nevins St
Ste 201
Brighton, MA 02135
Phone (617) 789-2442

736 Cambridge St
Brighton, MA 02135
Phone (617) 789-2762

1 Pearl St
Ste 1000
Brockton, MA 02301
Phone (508) 897-6050

100 Amesbury St
Ste 103
Lawrence, MA 01840
Phone (978) 683-0157

100 Industrial Park Rd
Ste 1
Taunton, MA 02780
Phone (508) 822-2266

2005 Bay St
Ste 201
Taunton, MA 02780
Phone (508) 822-2266

88 Washington St
Taunton, MA 02780
Phone (508) 828-7000

9 Galen St
Watertown, MA 02472
Phone (617) 562-5413

100 Brigham Way
Westwood, MA 02090
Phone (781) 471-2200

Interoperability endpoints

  • Direct secure messaging: derderian.kristen.bwh@direct.partners.masshiway.net

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1561593600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1647820800000",
    "number": "1407417645",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12200 WEBER HILL RD STE 100",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631271599",
            "telephone_number": "314-698-2500",
            "fax_number": "508-823-5689"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12200 WEBER HILL RD STE 100",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631271599",
            "telephone_number": "314-698-2500",
            "fax_number": "314-698-2323"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DERDERIAN",
        "first_name": "KRISTEN",
        "middle_name": "ALICE",
        "credential": "CNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-06-27",
        "last_updated": "2022-03-21",
        "certification_date": "2022-03-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "MA",
            "license": "RN2321686",
            "primary": false
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "MO",
            "license": "2021013574",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Louis, MO

Sources for this page

Verify at the official NPI Registry.