Provider Demographics
NPI:1629180690
Name:FREDERICK, MELISSA LYNN (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LYNN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:ARNP
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 607
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-0607
Mailing Address - Country:US
Mailing Address - Phone:606-743-3114
Mailing Address - Fax:606-743-1404
Practice Address - Street 1:430 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472
Practice Address - Country:US
Practice Address - Phone:606-743-3114
Practice Address - Fax:606-743-1404
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4360P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78012606Medicaid
Q31056Medicare UPIN
KY78012606Medicaid
KYP400035564Medicare PIN
KY183940Medicare Oscar/Certification