Provider Demographics
NPI:1225644560
Name:FREDERICK, KAILYNNE
Entity Type:Individual
Prefix:
First Name:KAILYNNE
Middle Name:
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 1:15 MANNERS AVE
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01220-1942
Mailing Address - Country:US
Mailing Address - Phone:413-663-0887
Mailing Address - Fax:
Practice Address - Street 1:15 MANNERS AVE
Practice Address - Street 2:
Practice Address - City:ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01220-1942
Practice Address - Country:US
Practice Address - Phone:413-663-0887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant