Provider Demographics
NPI:1639350333
Name:FROEDGE, TINA (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FROEDGE
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 RAINBOW DR
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 SARTIN DR.
Practice Address - Street 2:
Practice Address - City:EDMONTON
Practice Address - State:KY
Practice Address - Zip Code:42129
Practice Address - Country:US
Practice Address - Phone:270-432-4951
Practice Address - Fax:270-432-5054
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY27004019Medicaid