Provider Demographics
NPI:1255681433
Name:FREDERICK, ROBERTA MARIE (LVN)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:MARIE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1944 ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-3187
Mailing Address - Country:US
Mailing Address - Phone:559-300-8557
Mailing Address - Fax:
Practice Address - Street 1:1944 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-3187
Practice Address - Country:US
Practice Address - Phone:559-300-8557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN226782164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse