Provider Demographics
NPI:1104163740
Name:FREDRICKS, SARAH J (LPN)
Entity type:Individual
Prefix:MS
First Name:SARAH
Middle Name:J
Last Name:FREDRICKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0406
Mailing Address - Country:US
Mailing Address - Phone:608-718-9185
Mailing Address - Fax:
Practice Address - Street 1:1406 HOLIDAY DRIVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545
Practice Address - Country:US
Practice Address - Phone:608-718-9185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI302-45-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse