Provider Demographics
NPI:1033768866
Name:FREDERICK, NICOLE LEA (DNP, APRN,ACCNS-AG)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LEA
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:DNP, APRN,ACCNS-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 THISTLE PARK DR APT 5105
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1651
Mailing Address - Country:US
Mailing Address - Phone:817-907-6953
Mailing Address - Fax:
Practice Address - Street 1:2001 THISTLE PARK DR APT 5105
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1651
Practice Address - Country:US
Practice Address - Phone:817-907-6953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31465364SC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine