Provider Demographics
NPI:1750051090
Name:FREDERICK, MARIE ELISABETH (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ELISABETH
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 470408
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28247-0408
Mailing Address - Country:US
Mailing Address - Phone:704-887-6402
Mailing Address - Fax:704-887-6450
Practice Address - Street 1:1057 RED VENTURES DR STE 150
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29707-2518
Practice Address - Country:US
Practice Address - Phone:803-548-3708
Practice Address - Fax:704-887-6450
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.023784363LF0000X
SC26697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily