Provider Demographics
NPI:1316744642
Name:FREDERICK, MEKENNA (PA-C)
Entity type:Individual
Prefix:MS
First Name:MEKENNA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W JACKSON BLVD UNIT 803
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5641
Mailing Address - Country:US
Mailing Address - Phone:308-850-2552
Mailing Address - Fax:
Practice Address - Street 1:6140 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-2538
Practice Address - Country:US
Practice Address - Phone:773-435-9028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-08-27
Deactivation Date:2025-08-06
Deactivation Code:
Reactivation Date:2025-08-25
Provider Licenses
StateLicense IDTaxonomies
IL085.011483363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant