Provider Demographics
NPI:1780656082
Name:KRUKEMYER, REBECCA L (AUD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:L
Last Name:KRUKEMYER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:L
Other - Last Name:FREDERICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:133 E. FRONT ST. #687
Mailing Address - Street 2:PO BOX 687
Mailing Address - City:PEMBERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43450-0687
Mailing Address - Country:US
Mailing Address - Phone:419-287-2201
Mailing Address - Fax:419-287-2202
Practice Address - Street 1:133 EAST FRONT ST.
Practice Address - Street 2:
Practice Address - City:PEMBERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43450
Practice Address - Country:US
Practice Address - Phone:419-287-2201
Practice Address - Fax:419-287-2202
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA-00967231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4262611Medicare PIN