Provider Demographics
NPI:1346974896
Name:KELLY, DERRICK E
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:E
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6517 ROYAL OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-4805
Mailing Address - Country:US
Mailing Address - Phone:317-657-9382
Mailing Address - Fax:
Practice Address - Street 1:6517 ROYAL OAKLAND DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-4805
Practice Address - Country:US
Practice Address - Phone:317-657-9382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver