Provider Demographics
NPI:1619451697
Name:FREDERICK, TONYA (RN, FNP)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:TONYA
Other - Middle Name:
Other - Last Name:MICHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-735-2228
Mailing Address - Fax:817-735-2582
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-735-2228
Practice Address - Fax:817-735-2582
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1118906363LF0000X, 163W00000X
OR202100983NP-PP363LF0000X
OR202100811RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1118906OtherCERTIFIED NURSE PRACTITIONER
OR202100811RNOtherRN LICENSE
TX1118906OtherREGISTERED NURSE
OR202100983NP-PPOtherFNP/PRESRIBER