Healthcare Provider Details

I. General information

NPI: 1851702963
Provider Name (Legal Business Name): KERRA GREDNUK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EDDY STREET
PROVIDENCE RI
02905
US

IV. Provider business mailing address

35 EMERSON ST APT 1
NEW BEDFORD MA
02740-3657
US

V. Phone/Fax

Practice location:
  • Phone: 401-533-9000
  • Fax: 401-533-9101
Mailing address:
  • Phone: 401-952-3512
  • Fax: 401-533-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: