Provider Demographics
NPI:1467185082
Name:FREDERICK, LILLIE MINETTE (CRNP)
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:MINETTE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SUN TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-5919
Mailing Address - Country:US
Mailing Address - Phone:256-325-9111
Mailing Address - Fax:
Practice Address - Street 1:300 SUN TEMPLE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-5919
Practice Address - Country:US
Practice Address - Phone:256-325-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALF12210791363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner