Provider Demographics
NPI:1114376514
Name:DERRICKSON, KRYSTINA (CPM)
Entity type:Individual
Prefix:
First Name:KRYSTINA
Middle Name:
Last Name:DERRICKSON
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 S DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2740
Mailing Address - Country:US
Mailing Address - Phone:609-436-5769
Mailing Address - Fax:609-751-0905
Practice Address - Street 1:1901 S 9TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2384
Practice Address - Country:US
Practice Address - Phone:609-436-5769
Practice Address - Fax:609-751-0905
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MW00003300175M00000X
NH1063176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
Yes175M00000XOther Service ProvidersMidwife, LayGroup - Single Specialty