Provider Demographics
NPI:1861041691
Name:FREDRICK, GRACE E
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:E
Last Name:FREDRICK
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:PO BOX 2942
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98073-2942
Mailing Address - Country:US
Mailing Address - Phone:425-365-3875
Mailing Address - Fax:
Practice Address - Street 1:4702 MILL POND DR SE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-3801
Practice Address - Country:US
Practice Address - Phone:425-365-3875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60195794163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse