Provider Demographics
NPI:1841689395
Name:FREDERICK, KELLY (RN, MSN, FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RN, MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11842 ROCK LANDING DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4437
Mailing Address - Country:US
Mailing Address - Phone:757-873-0338
Mailing Address - Fax:757-873-9579
Practice Address - Street 1:11842 ROCK LANDING DR
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4437
Practice Address - Country:US
Practice Address - Phone:757-873-0338
Practice Address - Fax:757-873-9579
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172246363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily