Healthcare Provider Details

I. General information

NPI: 1417452012
Provider Name (Legal Business Name): KYLA FREDRICKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W SEMINOLE BLVD
SANFORD FL
32771-6743
US

IV. Provider business mailing address

8701 W WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

V. Phone/Fax

Practice location:
  • Phone: 608-397-4223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberME169827
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: