Provider Demographics
NPI:1336541549
Name:FREDRICK, PATRICIA LEE (PNP)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:LEE
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-6043
Mailing Address - Fax:888-463-6898
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV PED NEPHROLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6043
Practice Address - Fax:888-463-6898
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014023964363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420040522Medicaid