Provider Demographics
NPI:1639209489
Name:FREDERICKSEN, AMY M
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:FREDERICKSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 ARAPAHOE RD
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112
Mailing Address - Country:US
Mailing Address - Phone:303-338-4545
Mailing Address - Fax:
Practice Address - Street 1:5555 ARAPAHOE RD
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO118817163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
016520OtherKAISER-COMMERCIAL NUMBER