Provider Demographics
NPI:1932533924
Name:FREDRICKSON, LISA GAY (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GAY
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 E LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-3817
Mailing Address - Country:US
Mailing Address - Phone:707-972-0884
Mailing Address - Fax:
Practice Address - Street 1:205 SOUTH ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5540
Practice Address - Country:US
Practice Address - Phone:707-961-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA806740163W00000X
CA95026356363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse