Provider Demographics
NPI:1306516158
Name:FREDERICK, LEEANNA MARIE
Entity type:Individual
Prefix:
First Name:LEEANNA
Middle Name:MARIE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 THORNE CAMP RD
Mailing Address - Street 2:
Mailing Address - City:MANNINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26582-8205
Mailing Address - Country:US
Mailing Address - Phone:304-986-1661
Mailing Address - Fax:
Practice Address - Street 1:125 THORNE CAMP RD
Practice Address - Street 2:
Practice Address - City:MANNINGTON
Practice Address - State:WV
Practice Address - Zip Code:26582-8205
Practice Address - Country:US
Practice Address - Phone:304-986-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant