Provider Demographics
NPI:1497416481
Name:FEDELE, JIRINA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JIRINA
Middle Name:
Last Name:FEDELE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13859 LH RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:SD
Mailing Address - Zip Code:57738-5040
Mailing Address - Country:US
Mailing Address - Phone:706-945-4895
Mailing Address - Fax:
Practice Address - Street 1:3200 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8114
Practice Address - Country:US
Practice Address - Phone:605-719-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA095902164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse