Healthcare Provider Details

I. General information

NPI: 1427461920
Provider Name (Legal Business Name): DANIELLE DETELICH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE STE L119
LEXINGTON KY
40536-1552
US

IV. Provider business mailing address

740 S LIMESTONE STE L119
LEXINGTON KY
40536-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-257-3253
  • Fax: 859-323-1203
Mailing address:
  • Phone: 859-257-3253
  • Fax: 859-323-1203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number260094
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number58217
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: