Provider Demographics
NPI:1629598651
Name:FREDERICK, MCKENZIE CHERIE (APRN)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:CHERIE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 S DURBIN ST STE 108
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2566
Mailing Address - Country:US
Mailing Address - Phone:307-462-3569
Mailing Address - Fax:
Practice Address - Street 1:145 S DURBIN ST STE 108
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2566
Practice Address - Country:US
Practice Address - Phone:307-333-5756
Practice Address - Fax:307-439-2141
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY38068163W00000X
WY54604363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse