Provider Demographics
NPI:1720694292
Name:FREDERICK, ROSE MAXINE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MAXINE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 MYLES AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26362-1281
Mailing Address - Country:US
Mailing Address - Phone:304-643-4158
Mailing Address - Fax:
Practice Address - Street 1:521 SOUTH COURT STREET
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:WV
Practice Address - Zip Code:26362-2636
Practice Address - Country:US
Practice Address - Phone:304-643-4941
Practice Address - Fax:304-643-4936
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant