Healthcare Provider Details

I. General information

NPI: 1417630377
Provider Name (Legal Business Name): KYLEE DEROCHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 NC 24-87
CAMERON NC
28326-5201
US

IV. Provider business mailing address

113 HILLCREST DR
SANFORD NC
27330-4020
US

V. Phone/Fax

Practice location:
  • Phone: 919-777-0240
  • Fax: 919-777-0499
Mailing address:
  • Phone: 919-777-0240
  • Fax: 919-777-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP22452
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: