Provider Demographics
NPI:1972564433
Name:FREDRICKSON, ELAINE M (APRN)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:M
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5336 ANN ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:BOKEELIA
Mailing Address - State:FL
Mailing Address - Zip Code:33922-3016
Mailing Address - Country:US
Mailing Address - Phone:561-248-9297
Mailing Address - Fax:561-248-9297
Practice Address - Street 1:4700 N CONGRESS AVE
Practice Address - Street 2:STE 103
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3284
Practice Address - Country:US
Practice Address - Phone:561-255-3131
Practice Address - Fax:855-346-3451
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLARNP9186537207Q00000X
KY3014562363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100814330Medicaid
S42243Medicare UPIN