Provider Demographics
NPI:1245423805
Name:FREDERICKSON, RAELYNN (RN)
Entity Type:Individual
Prefix:
First Name:RAELYNN
Middle Name:
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT OF PHARMACY SERVICES RMA050
Mailing Address - Street 2:50 N MEDICAL DRIVE
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-585-3965
Mailing Address - Fax:801-585-0403
Practice Address - Street 1:DEPARTMENT OF PHARMACY SERVICES RMA050
Practice Address - Street 2:50 N MEDICAL DRIVE
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-585-3965
Practice Address - Fax:801-585-0403
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT378181-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse