Provider Demographics
NPI:1104250893
Name:FREDERICK, STACY ROSE (APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ROSE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2312 ALEXANDRIA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3229
Mailing Address - Country:US
Mailing Address - Phone:859-276-5344
Mailing Address - Fax:859-296-0362
Practice Address - Street 1:2400 GREATSTONE PT STE A100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3274
Practice Address - Country:US
Practice Address - Phone:859-323-7246
Practice Address - Fax:859-257-6768
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily