Provider Demographics
NPI:1982008793
Name:MARTIN, FREDERICKA (LPN)
Entity Type:Individual
Prefix:
First Name:FREDERICKA
Middle Name:
Last Name:MARTIN
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 1:9723 WINGED TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4695
Mailing Address - Country:US
Mailing Address - Phone:704-777-8504
Mailing Address - Fax:
Practice Address - Street 1:110 HOWARD LN
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-6817
Practice Address - Country:US
Practice Address - Phone:704-777-8504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC47-19724120101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor