Mary Joy E Derla
Individual provider Active NPI Family Nurse Practitioner · Fort Totten, ND
NPI 1407686231 · NPPES record last updated Aug 6, 2024
Key facts
- NPI
- 1407686231
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Nurse Practitioner 363LF0000X
- License
- 200103 (ND)
- Practice address
- 3883 74TH Avenue NE
Fort Totten, ND 58335 - Phone
- (701) 766-1600
- NPI assigned
- Aug 6, 2024
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare Care Compare profile
- Specialty
- Nurse Practitioner
- Education
- Other, 2024
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Spirit Lake Tribe
Practice addresses (Care Compare)
3883 74TH Ave NE
Spirit Lake Health Center
Fort Totten, ND 58335-0309
Phone (701) 766-1600
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20241002000955 | TX | Practitioner - Nurse Practitioner | 0143751198 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 200103 | ND | MD | Family Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Spirit Lake Tribe | Current |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | 200103 | ND | Yes |
Addresses
Primary practice location
3883 74TH Avenue NE
Fort Totten, ND 58335
Mailing address
1401 3Rd St NE Apt E
Devils Lake, ND 58301-3323
Phone (701) 350-2409
Other providers in Fort Totten, ND
- Kenda Cohen
- Angela I Cross
- Nancy C Dauphinais
- Kyla Sarah Delorme
- Shaylynn F Demarrias
- Georgalene Dubois
- Linda F Duckwitz
- Emmarae Jean Dunn
- Morrissa Rose Dunn
- Helen Marie Early
All providers in Fort Totten, ND · Family Nurse Practitioner in North Dakota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 6, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.