Provider Demographics
NPI:1316405657
Name:FREDRICK, LISA KAY (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KAY
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-5085
Mailing Address - Fax:208-625-5731
Practice Address - Street 1:700 W IRONWOOD DR STE 350
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4487
Practice Address - Country:US
Practice Address - Phone:208-625-5230
Practice Address - Fax:208-625-5231
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP60945363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner