Provider Demographics
NPI:1679047609
Name:FREDERICK, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:6005 LAFAYETTE DR
Mailing Address - Street 2:
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1422 EUCLID AVE STE 802
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2001
Practice Address - Country:US
Practice Address - Phone:401-584-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-12
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOC.000024156FX1700X
156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist