Provider Demographics
NPI:1972971844
Name:FREDERICK, DIANE T (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:T
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:FNP-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 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-2635
Mailing Address - Country:US
Mailing Address - Phone:270-999-2731
Mailing Address - Fax:
Practice Address - Street 1:1010 W LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-1640
Practice Address - Country:US
Practice Address - Phone:267-273-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015164363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily