Provider Demographics
NPI:1073817011
Name:FEDDELER, KATHRYN A (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:A
Last Name:FEDDELER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 SMOKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3489
Mailing Address - Country:US
Mailing Address - Phone:719-599-7289
Mailing Address - Fax:
Practice Address - Street 1:1690 SMOKE RIDGE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3489
Practice Address - Country:US
Practice Address - Phone:719-599-7289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAA435511174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COAA435511OtherOT LICENSE