Healthcare Provider Details

I. General information

NPI: 1255294633
Provider Name (Legal Business Name): BRISEIDA RUBI CARDENAS FREDRICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18033 DRY SLOUGH RD
MOUNT VERNON WA
98273-9568
US

IV. Provider business mailing address

18033 DRY SLOUGH RD
MOUNT VERNON WA
98273-9568
US

V. Phone/Fax

Practice location:
  • Phone: 425-591-1862
  • Fax:
Mailing address:
  • Phone: 425-591-1862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License NumberBDC.BD.70032761
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: