Provider Demographics
NPI:1194547208
Name:FREDERICKS, RAYNETTE (LPN)
Entity type:Individual
Prefix:
First Name:RAYNETTE
Middle Name:
Last Name:FREDERICKS
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 1:1970 NE FUSON RD APT 204
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-3739
Mailing Address - Country:US
Mailing Address - Phone:786-518-8971
Mailing Address - Fax:
Practice Address - Street 1:1520 NE RIDDELL RD # 110
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3005
Practice Address - Country:US
Practice Address - Phone:786-518-8971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5173031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse