Healthcare Provider Details

I. General information

NPI: 1518409887
Provider Name (Legal Business Name): ANGELIA FREDERICK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2016
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SIOUX DRIVE
CHAMBERLAIN SD
57325
US

IV. Provider business mailing address

100 SIOUX DR
CHAMBERLAIN SD
57325-1742
US

V. Phone/Fax

Practice location:
  • Phone: 605-730-5639
  • Fax:
Mailing address:
  • Phone: 605-730-5639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR029072
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP001170
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: