Provider Demographics
NPI:1932100849
Name:FREDRICK, JULIE R (APNP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:R
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MEMORIAL DR
Mailing Address - Street 2:STE 1200
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-5770
Mailing Address - Fax:920-361-5779
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:STE 1200
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5770
Practice Address - Fax:920-361-5779
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI99850-030163W00000X
WI1682-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43827900Medicaid
WI43827900Medicaid
WI007900416Medicare PIN