Provider Demographics
NPI:1760157234
Name:FREDRICKSON, MA. THERESA CORPUZ (DNP, AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:MA. THERESA
Middle Name:CORPUZ
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:DNP, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 W CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-5105
Mailing Address - Country:US
Mailing Address - Phone:715-717-1467
Mailing Address - Fax:715-717-6184
Practice Address - Street 1:900 W CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6122
Practice Address - Country:US
Practice Address - Phone:715-717-1469
Practice Address - Fax:715-717-6184
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI11200-33363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology