Provider Demographics
NPI:1609915636
Name:FEDDE, ADRIENE KIM (MD)
Entity Type:Individual
Prefix:
First Name:ADRIENE KIM
Middle Name:
Last Name:FEDDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-0150
Mailing Address - Country:US
Mailing Address - Phone:505-819-8996
Mailing Address - Fax:
Practice Address - Street 1:103 FRAM STREET
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833
Practice Address - Country:US
Practice Address - Phone:505-819-8996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0054942207Q00000X
AK7230207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine