Provider Demographics
NPI:1285620674
Name:FREDERE, GAYLE S (CRNA)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:S
Last Name:FREDERE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6508 BIENVILLE CT
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-3259
Mailing Address - Country:US
Mailing Address - Phone:251-709-6980
Mailing Address - Fax:
Practice Address - Street 1:6508 BIENVILLE CT
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-3259
Practice Address - Country:US
Practice Address - Phone:251-709-6980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-024624207L00000X
AL1024624367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL115135OtherMEDICAID AOC
AL511-00430OtherBCBS OF ALABAMA SMC
AL511-00442OtherBCBS OF AL - AOC
AL051057537OtherBC OF AL
AL000057537Medicaid
AL115141OtherMEDICAID SMC
AL511-00430OtherBCBS OF ALABAMA SMC
AL000057537Medicaid