Provider Demographics
NPI:1396354601
Name:FRIDDLE, KELLY-KATHERINE MARIE
Entity type:Individual
Prefix:
First Name:KELLY-KATHERINE
Middle Name:MARIE
Last Name:FRIDDLE
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 1:72 HINKLE DR
Mailing Address - Street 2:
Mailing Address - City:MOOREFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:26836-9160
Mailing Address - Country:US
Mailing Address - Phone:304-490-8288
Mailing Address - Fax:
Practice Address - Street 1:12 MAPLE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847
Practice Address - Country:US
Practice Address - Phone:304-257-9298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant