Provider Demographics
NPI:1083022768
Name:FREDRICKSON, NICOLE LYNN (RN)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LYNN
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5034 STAR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-6304
Mailing Address - Country:US
Mailing Address - Phone:715-829-0489
Mailing Address - Fax:
Practice Address - Street 1:5034 STAR RIDGE RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-6304
Practice Address - Country:US
Practice Address - Phone:715-829-0489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI194229-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse