Provider Demographics
NPI:1912458001
Name:FREDERICK, AMBER NICOLE (RDN, LD, CNSC)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:NICOLE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:RDN, LD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5463 CALKINS AVE SW
Mailing Address - Street 2:
Mailing Address - City:KALONA
Mailing Address - State:IA
Mailing Address - Zip Code:52247-9140
Mailing Address - Country:US
Mailing Address - Phone:319-321-8354
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered