Provider Demographics
NPI:1346852365
Name:FREDRICKSON, AMANDA KRISTINE (RD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KRISTINE
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 SE 64TH AVE.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206
Mailing Address - Country:US
Mailing Address - Phone:503-494-8300
Mailing Address - Fax:
Practice Address - Street 1:3611 SE 64TH AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206
Practice Address - Country:US
Practice Address - Phone:503-494-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered