Provider Demographics
NPI:1205399284
Name:FREDERICK, ANEL
Entity Type:Individual
Prefix:
First Name:ANEL
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 SW 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-3609
Mailing Address - Country:US
Mailing Address - Phone:954-899-6880
Mailing Address - Fax:
Practice Address - Street 1:1322 SW 74TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-3609
Practice Address - Country:US
Practice Address - Phone:954-899-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities