Healthcare Provider Details

I. General information

NPI: 1861583510
Provider Name (Legal Business Name): FREDERICKSBURG NEPHROLOGY ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PARK HILL DR
FREDERICKSBURG VA
22401-3357
US

IV. Provider business mailing address

101 PARK HILL DR
FREDERICKSBURG VA
22401-3357
US

V. Phone/Fax

Practice location:
  • Phone: 540-371-3010
  • Fax: 540-899-9821
Mailing address:
  • Phone: 540-371-3010
  • Fax: 540-899-9821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateVA

VIII. Authorized Official

Name: TAMMY PROVENCHER
Title or Position: CREDENTIALING SUPERVISOR
Credential: PROVENCHER
Phone: 540-371-3010