Provider Demographics
NPI:1639478860
Name:FREDERICK, THERESA A
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:A
Last Name:FREDERICK
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 1:496 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-5135
Mailing Address - Country:US
Mailing Address - Phone:610-933-9483
Mailing Address - Fax:610-933-4080
Practice Address - Street 1:1288 VALLEY FORGE RD
Practice Address - Street 2:UNIT 69
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-2687
Practice Address - Country:US
Practice Address - Phone:610-933-9483
Practice Address - Fax:610-933-4080
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN273868164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse