Provider Demographics
NPI:1992411854
Name:FREDERICK, MARIE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
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 1:2113 ALICE AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:FOREST HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20745-3511
Mailing Address - Country:US
Mailing Address - Phone:240-425-7650
Mailing Address - Fax:
Practice Address - Street 1:2113 ALICE AVE APT 101
Practice Address - Street 2:
Practice Address - City:FOREST HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20745-3511
Practice Address - Country:US
Practice Address - Phone:240-425-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10006353900Medicaid