Provider Demographics
NPI:1871189977
Name:FREDRICK, MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9259 LAKE FISCHER BLVD
Mailing Address - Street 2:
Mailing Address - City:GOTHA
Mailing Address - State:FL
Mailing Address - Zip Code:34734-5204
Mailing Address - Country:US
Mailing Address - Phone:407-346-2585
Mailing Address - Fax:
Practice Address - Street 1:9259 LAKE FISCHER BLVD
Practice Address - Street 2:
Practice Address - City:GOTHA
Practice Address - State:FL
Practice Address - Zip Code:34734-5204
Practice Address - Country:US
Practice Address - Phone:407-346-2585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN1331581164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse