Provider Demographics
NPI:1225366925
Name:FADDIS, KRISTY H
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:H
Last Name:FADDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 COUNTRY WAY
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-9517
Mailing Address - Country:US
Mailing Address - Phone:307-789-2875
Mailing Address - Fax:307-789-2876
Practice Address - Street 1:164 COUNTRY WAY
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9517
Practice Address - Country:US
Practice Address - Phone:307-789-2875
Practice Address - Fax:307-789-2876
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY251C00000X385H00000X, 385HR2055X, 385HR2060X, 385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child