Provider Demographics
NPI:1679325393
Name:FADDIS, KRISTY ELLEN
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:ELLEN
Last Name:FADDIS
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 1:6020 FORT AMANDA RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-4454
Mailing Address - Country:US
Mailing Address - Phone:209-202-2564
Mailing Address - Fax:
Practice Address - Street 1:6020 FORT AMANDA RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-4454
Practice Address - Country:US
Practice Address - Phone:209-202-2564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide