Healthcare Provider Details

I. General information

NPI: 1114882388
Provider Name (Legal Business Name): SHAYDA FREDERICKSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

2570 LYNN RD
CHAPPELL HILL TX
77426-2800
US

IV. Provider business mailing address

18611 MELISSA AVE
SANDY OR
97055-6886
US

V. Phone/Fax

Practice location:
  • Phone: 713-589-5283
  • Fax:
Mailing address:
  • Phone: 713-589-5283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10054393
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: