Provider Demographics
NPI:1043414667
Name:PIPPIN, KERRY RAE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:RAE
Last Name:PIPPIN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 CRANBERRY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99712-1102
Mailing Address - Country:US
Mailing Address - Phone:907-347-6494
Mailing Address - Fax:
Practice Address - Street 1:415 1ST AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4722
Practice Address - Country:US
Practice Address - Phone:907-347-6494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2009-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5888235Z00000X
AK129235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist