Healthcare Provider Details

I. General information

NPI: 1609915636
Provider Name (Legal Business Name): ADRIENE KIM FEDDE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 FRAM STREET
PETERSBURG AK
99833
US

IV. Provider business mailing address

PO BOX 150
FRISCO CO
80443-0150
US

V. Phone/Fax

Practice location:
  • Phone: 505-819-8996
  • Fax:
Mailing address:
  • Phone: 505-819-8996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0054942
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7230
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: