Basic Information
| Provider Information | |||||||||
| NPI: | 1750051090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | ELISABETH | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 470408 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282470408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048876402 | ||||||||
| FaxNumber: | 7048876450 | ||||||||
| Practice Location | |||||||||
| Address1: | 1057 RED VENTURES DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | FORT MILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297072518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035483708 | ||||||||
| FaxNumber: | 7048876450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2021 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209.023784 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 26697 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.