=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568839082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERRI FEDETZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2015
-----------------------------------------------------
Last Update Date | 08/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 903 COVENTRY DR
-----------------------------------------------------
City | PHILLIPSBURG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08865-1974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-454-4611
-----------------------------------------------------
Fax | 908-454-8876
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 903 COVENTRY DR
-----------------------------------------------------
City | PHILLIPSBURG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08865-1974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-454-4611
-----------------------------------------------------
Fax | 908-454-8876
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 41YA00093500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | F03526
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 25MG00136000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------