Provider Demographics
NPI:1881393585
Name:DERRICK, KAYLA (CSFA)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:DERRICK
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 823
Mailing Address - Street 2:
Mailing Address - City:CLOUDCROFT
Mailing Address - State:NM
Mailing Address - Zip Code:88317-0823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2669 SCENIC DR
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-8700
Practice Address - Country:US
Practice Address - Phone:575-439-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM206485246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant