Healthcare Provider Details

I. General information

NPI: 1255273785
Provider Name (Legal Business Name): TATEM FREDRICKSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 LINCOLN WAY STE 315
COEUR D ALENE ID
83814-2527
US

IV. Provider business mailing address

1219 E WASHINGTON ST
BOISE ID
83712-7328
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-4255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: