Provider Demographics
NPI:1568012896
Name:FREDERICK, TRACEY (APRN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
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:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:3602 NORTHGATE CT STE 39
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6417
Practice Address - Country:US
Practice Address - Phone:812-670-5684
Practice Address - Fax:812-941-0814
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013585363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
7247386OtherUNITED HEALTHCARE PROVIDER ID NUMBER
KY7100625390Medicaid
KYPDZ000000382486OtherAETNA BETTER HEALTH OF KY PROVIDER ID NUMBER
KY2061379OtherWELLCARE OF KY PROVIDER ID NUMBER
IN300030681Medicaid
CS2003600170OtherCARESOURCE PROVIDER ID NUMBER
000001318458OtherANTHEM PROVIDER ID NUMBER