Provider Demographics
NPI:1275924433
Name:FREDERICK, NEELY RICHARDSON (NP-C)
Entity Type:Individual
Prefix:
First Name:NEELY
Middle Name:RICHARDSON
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:NEELY
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:4400 UNIVERSITY DR BLDG 1
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-4444
Mailing Address - Country:US
Mailing Address - Phone:703-993-2831
Mailing Address - Fax:703-993-4365
Practice Address - Street 1:4400 UNIVERSITY DR BLDG 1
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-4444
Practice Address - Country:US
Practice Address - Phone:703-993-2831
Practice Address - Fax:703-993-4365
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0000992363L00000X
NC5007466363LF0000X
VA0024185660363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner