Provider Demographics
NPI:1750039046
Name:FREDERICKS, DOLORES LEOPOLD
Entity Type:Individual
Prefix:MISS
First Name:DOLORES
Middle Name:LEOPOLD
Last Name:FREDERICKS
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 1:3800 VICTORY PKWY UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45207-1092
Mailing Address - Country:US
Mailing Address - Phone:615-601-4495
Mailing Address - Fax:
Practice Address - Street 1:3800 VICTORY PKWY UNIT 1
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45207-1092
Practice Address - Country:US
Practice Address - Phone:615-601-4495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program