Healthcare Provider Details

I. General information

NPI: 1114376514
Provider Name (Legal Business Name): KRYSTINA DERRICKSON CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 05/20/2024
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 S 9TH ST
PHILADELPHIA PA
19148-2384
US

IV. Provider business mailing address

419 S DUNCAN ST
BALTIMORE MD
21231-2740
US

V. Phone/Fax

Practice location:
  • Phone: 609-436-5769
  • Fax: 609-751-0905
Mailing address:
  • Phone: 609-436-5769
  • Fax: 609-751-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number25MW00003300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: