Provider Demographics
NPI:1134100886
Name:FREDERICK, KATHRYN LEIGH
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:LEIGH
Last Name:FREDERICK
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 1:1514 HATCHER LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4825
Mailing Address - Country:US
Mailing Address - Phone:931-381-7591
Mailing Address - Fax:
Practice Address - Street 1:1514 HATCHER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4825
Practice Address - Country:US
Practice Address - Phone:931-381-7591
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN#39011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
47009OtherAMERITAS
60054OtherAETNA
61271OtherPRINCIPAL
62308OtherCIGNA
CDAR1OtherDELTA ARKANSAS
CDTN1OtherDELTA TENNESSEE
10050OtherCIGNA (RUBY TUESDAY)
52133OtherUNITED HEALTH CARE
70408OtherFORTIS
CDMIOOtherDELTA MICHIGAN
67814OtherGE FINANCIAL
84056OtherDELTA COLORADO
CBTN1OtherBCBS TENNESSEE
58066OtherAFLAC
87726OtherCIGNA (CRACKER BARREL)
CDMN1OtherDELTA MINNESOTA
64246OtherGUARDIAN
65978OtherMETLIFE
94276OtherDELTA GEORGIA