Provider Demographics
NPI:1376024570
Name:FREDRICKSON, COURTNEY NICOLE (DC)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:NICOLE
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 N HIGHLAND AVE NE APT 16
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-1449
Mailing Address - Country:US
Mailing Address - Phone:616-821-7134
Mailing Address - Fax:
Practice Address - Street 1:483 MORELAND AVE NE STE 1
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-1530
Practice Address - Country:US
Practice Address - Phone:616-821-7134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010090111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor