Provider Demographics
NPI:1780987487
Name:FREDERICKSON, DELORA MARIE
Entity type:Individual
Prefix:
First Name:DELORA
Middle Name:MARIE
Last Name:FREDERICKSON
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 1:8104 NOTTAWAY CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-7419
Mailing Address - Country:US
Mailing Address - Phone:512-775-3053
Mailing Address - Fax:
Practice Address - Street 1:3823 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78722-1300
Practice Address - Country:US
Practice Address - Phone:512-522-2433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-19
Last Update Date:2010-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula