Provider Demographics
NPI:1053645317
Name:FREDRICKSON, BROOKE LEIGH (LRD, CSG)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:LEIGH
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:LRD, CSG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 COUNTY ROAD 19
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58425-9168
Mailing Address - Country:US
Mailing Address - Phone:701-361-7154
Mailing Address - Fax:
Practice Address - Street 1:1200 ROBERTS AVE NE
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:ND
Practice Address - Zip Code:58425-7101
Practice Address - Country:US
Practice Address - Phone:701-797-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND669133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered