Provider Demographics
NPI:1093362105
Name:FRIDERES, BEVERLY
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:FRIDERES
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 1:4827 LAKEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:IA
Mailing Address - Zip Code:50211
Mailing Address - Country:US
Mailing Address - Phone:515-210-0420
Mailing Address - Fax:
Practice Address - Street 1:4827 LAKEWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:IA
Practice Address - Zip Code:50211
Practice Address - Country:US
Practice Address - Phone:515-210-0420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider