Healthcare Provider Details

I. General information

NPI: 1619245875
Provider Name (Legal Business Name): MELISSA A FREDRICKSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 VILLAGE COMMONS DR
ST AUGUSTINE FL
32092-4545
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-940-1441
  • Fax: 904-390-7463
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106223
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: