Provider Demographics
NPI:1497222681
Name:FREDERICKS, ALYSSA L
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:L
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:KYKOTSMOVI
Mailing Address - State:AZ
Mailing Address - Zip Code:86039-0032
Mailing Address - Country:US
Mailing Address - Phone:928-514-3402
Mailing Address - Fax:
Practice Address - Street 1:HWY 264 MILEPOST 388
Practice Address - Street 2:UNIT 40
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-0414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZATR-0016762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer