Provider Demographics
NPI:1497984603
Name:FREDERICK, CARLIE ANN (APRN)
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:ANN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6026 CHRISBIN DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-3738
Mailing Address - Country:US
Mailing Address - Phone:706-593-7701
Mailing Address - Fax:
Practice Address - Street 1:2000 16TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1665
Practice Address - Country:US
Practice Address - Phone:706-320-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2015-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN095043363LP0200X, 364SP0807X, 364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult