Healthcare Provider Details

I. General information

NPI: 1477711562
Provider Name (Legal Business Name): KRISTIN LINNEA EIDAM M.S., CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 MAIN ST
WAKEFIELD RI
02879-3566
US

IV. Provider business mailing address

116 MAIN ST
WAKEFIELD RI
02879-3566
US

V. Phone/Fax

Practice location:
  • Phone: 401-782-4400
  • Fax: 401-782-4994
Mailing address:
  • Phone: 401-782-4400
  • Fax: 401-782-4994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAUD00176
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: