Provider Demographics
NPI:1528507357
Name:FREDRICKSON, AMY D (LMP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:D
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 S 216TH ST
Mailing Address - Street 2:APT 103D
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-8363
Mailing Address - Country:US
Mailing Address - Phone:907-738-2116
Mailing Address - Fax:
Practice Address - Street 1:1208 S 216TH ST
Practice Address - Street 2:APT 103D
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-8363
Practice Address - Country:US
Practice Address - Phone:907-738-2116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60722244171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor