Provider Demographics
NPI:1851702963
Name:GREDNUK, KERRA
Entity Type:Individual
Prefix:
First Name:KERRA
Middle Name:
Last Name:GREDNUK
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 1:35 EMERSON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-3657
Mailing Address - Country:US
Mailing Address - Phone:401-952-3512
Mailing Address - Fax:401-533-9101
Practice Address - Street 1:1000 EDDY STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905
Practice Address - Country:US
Practice Address - Phone:401-533-9000
Practice Address - Fax:401-533-9101
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIES01788Medicaid