Provider Demographics
NPI:1982251849
Name:FREDERICK, ELIZABETH RAE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RAE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SHIPLEY LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:PA
Mailing Address - Zip Code:15666-3521
Mailing Address - Country:US
Mailing Address - Phone:724-544-3424
Mailing Address - Fax:
Practice Address - Street 1:680 BLAIR MILL RD
Practice Address - Street 2:
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-2223
Practice Address - Country:US
Practice Address - Phone:724-544-3424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-24
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020656363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily