Provider Demographics
NPI:1639553902
Name:FREDRICK, CHERYL LYNN (LPN)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:LYNN
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 ELY ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-1336
Mailing Address - Country:US
Mailing Address - Phone:573-717-7059
Mailing Address - Fax:
Practice Address - Street 1:925 HIGHWAY V V
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857
Practice Address - Country:US
Practice Address - Phone:573-717-7059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006025554172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker