Provider Demographics
NPI:1710483219
Name:FREDERICKSON, ABBY NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:NICOLE
Last Name:FREDERICKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8701 WATERTOWN PLANK RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3548
Mailing Address - Country:US
Mailing Address - Phone:414-955-6777
Mailing Address - Fax:414-955-0069
Practice Address - Street 1:8701 WATERTOWN PLANK RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3548
Practice Address - Country:US
Practice Address - Phone:414-955-6777
Practice Address - Fax:414-955-0069
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9583207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics