Provider Demographics
NPI:1912957408
Name:FREDRICKSON, KRISTIN LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:LEE
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:FREDRICKSON
Other - Last Name:RECKMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3605 MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2923
Mailing Address - Country:US
Mailing Address - Phone:218-262-3441
Mailing Address - Fax:218-362-6989
Practice Address - Street 1:3605 MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2923
Practice Address - Country:US
Practice Address - Phone:218-262-3441
Practice Address - Fax:218-362-6989
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48615207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN48615OtherMN LIC