Healthcare Provider Details

I. General information

NPI: 1396409264
Provider Name (Legal Business Name): KELYEA S DERRICKS-LINDER CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 YOLANDA DR # 2
DAYTON OH
45417-4467
US

IV. Provider business mailing address

2505 YOLANDA DR # 2
DAYTON OH
45417-4467
US

V. Phone/Fax

Practice location:
  • Phone: 937-241-5994
  • Fax: 937-660-6876
Mailing address:
  • Phone: 937-241-5994
  • Fax: 937-660-6876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberOH22332E614
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: