Basic Information
| Provider Information | |||||||||
| NPI: | 1427044726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 SAMARITAN AVE | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448053927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197565133 | ||||||||
| FaxNumber: | 4197749707 | ||||||||
| Practice Location | |||||||||
| Address1: | 799 LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449071906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197565133 | ||||||||
| FaxNumber: | 4197749707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN193878 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2290668 | 05 | OH | MEDICAID |