Provider Demographics
NPI:1275560625
Name:FEDELE, KATHIE
Entity Type:Individual
Prefix:MS
First Name:KATHIE
Middle Name:
Last Name:FEDELE
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 1:401 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-3929
Mailing Address - Country:US
Mailing Address - Phone:401-962-8917
Mailing Address - Fax:
Practice Address - Street 1:2324 W JOPPA RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4615
Practice Address - Country:US
Practice Address - Phone:443-416-8916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16626174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD860LMedicare ID - Type Unspecified