Provider Demographics
NPI:1992570832
Name:FREDERICK, MARY (LPN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8310 MILL CREEK LN
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-2527
Mailing Address - Country:US
Mailing Address - Phone:727-514-3543
Mailing Address - Fax:
Practice Address - Street 1:4041 ROWAN RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-6121
Practice Address - Country:US
Practice Address - Phone:727-284-1980
Practice Address - Fax:727-284-1981
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5216595164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse