Provider Demographics
NPI:1922610278
Name:FREDETTE, KRISTINA W
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:W
Last Name:FREDETTE
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 1:1 HAYDEN BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1347
Mailing Address - Country:US
Mailing Address - Phone:541-868-9430
Mailing Address - Fax:541-868-9450
Practice Address - Street 1:34182 THUNDER CLOUD DR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-9632
Practice Address - Country:US
Practice Address - Phone:541-514-8009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR012076235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist