Provider Demographics
NPI:1093409997
Name:FREDERIKSEN, KRISTEN KELLY (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:KELLY
Last Name:FREDERIKSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4779 S FOREST POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7476
Mailing Address - Country:US
Mailing Address - Phone:262-894-4193
Mailing Address - Fax:
Practice Address - Street 1:4779 S FOREST POINT BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7476
Practice Address - Country:US
Practice Address - Phone:262-894-4193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14040-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100261245Medicaid