Provider Demographics
NPI:1265681332
Name:FREDERICK, JA'NAI XZANA TELLIS (OD)
Entity Type:Individual
Prefix:
First Name:JA'NAI
Middle Name:XZANA TELLIS
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1118
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-9123
Mailing Address - Country:US
Mailing Address - Phone:804-748-4877
Mailing Address - Fax:804-796-9168
Practice Address - Street 1:9440 IRON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6601
Practice Address - Country:US
Practice Address - Phone:804-748-4877
Practice Address - Fax:804-796-9168
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-15
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001758152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist