Provider Demographics
NPI:1588339048
Name:FREDRICK, BREANNA KATHLEEN (AA)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:KATHLEEN
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 NW 93RD TER
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-5236
Mailing Address - Country:US
Mailing Address - Phone:646-279-3423
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:646-279-3423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant