Provider Demographics
NPI:1396409264
Name:DERRICKS-LINDER, KELYEA S (CPT)
Entity Type:Individual
Prefix:
First Name:KELYEA
Middle Name:S
Last Name:DERRICKS-LINDER
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 YOLANDA DR # 2
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-4467
Mailing Address - Country:US
Mailing Address - Phone:937-241-5994
Mailing Address - Fax:937-660-6876
Practice Address - Street 1:2505 YOLANDA DR # 2
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-4467
Practice Address - Country:US
Practice Address - Phone:937-241-5994
Practice Address - Fax:937-660-6876
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH22332E614246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy