Healthcare Provider Details

I. General information

NPI: 1386112100
Provider Name (Legal Business Name): AMANDA MARIE FREDERICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2018
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7349 STATESVILLE RD # B
CHARLOTTE NC
28269-3702
US

IV. Provider business mailing address

8936 CYPRESS FOREST DR
CHARLOTTE NC
28216-1674
US

V. Phone/Fax

Practice location:
  • Phone: 866-550-3472
  • Fax: 704-973-7875
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08418
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: