Provider Demographics
NPI:1801642087
Name:FREDERICK, ALEXYIS (CPT, CCMA)
Entity type:Individual
Prefix:MS
First Name:ALEXYIS
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:CPT, CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3831 HOHMAN AVE # 1072
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46327-1160
Mailing Address - Country:US
Mailing Address - Phone:872-256-0655
Mailing Address - Fax:
Practice Address - Street 1:3831 HOHMAN AVE # 1072
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46327-1160
Practice Address - Country:US
Practice Address - Phone:872-256-0655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-27
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3877-6669261Q00000X
AL3811-6669246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center