Provider Demographics
NPI:1952778441
Name:FREDRICK, KAITLYN VICTORIA (APN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:VICTORIA
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:APN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 JOSEPHINE ST NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-2002
Mailing Address - Country:US
Mailing Address - Phone:901-496-3631
Mailing Address - Fax:
Practice Address - Street 1:1525 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4200
Practice Address - Country:US
Practice Address - Phone:404-727-6145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201509309NP-PP363LP0808X
GARN290699363LP0808X
WAAP60596057363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health