Basic Information
Provider Information | |||||||||
NPI: | 1821299975 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FREDERICK | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 858 CO RD 20 | ||||||||
Address2: |   | ||||||||
City: | DILLONVALE | ||||||||
State: | OH | ||||||||
PostalCode: | 43917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1740733728 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 508 MEDICAL PARK | ||||||||
Address2: |   | ||||||||
City: | WHEELING | ||||||||
State: | WV | ||||||||
PostalCode: | 26003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042438916 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2007 | ||||||||
LastUpdateDate: | 12/10/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 51393 | WV | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 3810010317 | 05 | WV |   | MEDICAID |