Provider Demographics
NPI:1194780288
Name:FREDERICK, ANITA LYNN (RN)
Entity type:Individual
Prefix:MISS
First Name:ANITA
Middle Name:LYNN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4736 WAISANEN RD
Mailing Address - Street 2:
Mailing Address - City:EMBARRASS
Mailing Address - State:MN
Mailing Address - Zip Code:55732-8346
Mailing Address - Country:US
Mailing Address - Phone:218-780-3164
Mailing Address - Fax:218-984-3603
Practice Address - Street 1:29250 COUNTY HWY E
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:WI
Practice Address - Zip Code:54856-1072
Practice Address - Country:US
Practice Address - Phone:715-765-4791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI160826-030163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health