Provider Demographics
NPI:1104237544
Name:FREDERICKSON, KATIE LEE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:LEE
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2438 N PONDEROSA DR
Mailing Address - Street 2:C-105
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-2369
Mailing Address - Country:US
Mailing Address - Phone:805-388-2068
Mailing Address - Fax:805-484-7700
Practice Address - Street 1:2438 N PONDEROSA DR
Practice Address - Street 2:C-105
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2369
Practice Address - Country:US
Practice Address - Phone:805-388-2068
Practice Address - Fax:805-484-7700
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95000513363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily