Provider Demographics
NPI:1205093911
Name:FREDERICK, ANNIE (RDT)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1576
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156-1576
Mailing Address - Country:US
Mailing Address - Phone:509-921-6560
Mailing Address - Fax:
Practice Address - Street 1:11703 E SPRAGUE AVE STE C3
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6129
Practice Address - Country:US
Practice Address - Phone:509-921-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000556133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA00719636OtherADA NUMBER
WADI00000556OtherWA CERTIFICATION NUMBER
WA8260051OtherPROVIDER NUMBER
WA9051731Medicaid
WA8260051OtherPROVIDER NUMBER