Provider Demographics
NPI:1871261842
Name:FREDERICK, BROOKE LAUREN (RN)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LAUREN
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5950 W INDIAN SHADOW DR
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-8892
Mailing Address - Country:US
Mailing Address - Phone:602-303-4949
Mailing Address - Fax:
Practice Address - Street 1:5950 W INDIAN SHADOW DR
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85742-8892
Practice Address - Country:US
Practice Address - Phone:602-303-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ242311163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty