Provider Demographics
NPI:1619076221
Name:FREDERICK, DARLENE LINDSTROM (NP)
Entity Type:Individual
Prefix:MRS
First Name:DARLENE
Middle Name:LINDSTROM
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 BROOK FOREST AVE UNIT F
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-8515
Mailing Address - Country:US
Mailing Address - Phone:815-725-4918
Mailing Address - Fax:815-725-4955
Practice Address - Street 1:850 BROOK FOREST AVE UNIT F
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-8515
Practice Address - Country:US
Practice Address - Phone:815-725-4918
Practice Address - Fax:815-725-4955
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-002559363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL556410001Medicare PIN