Healthcare Provider Details

I. General information

NPI: 1932100849
Provider Name (Legal Business Name): JULIE R FREDRICK APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEMORIAL DR STE 1200
BERLIN WI
54923-1243
US

IV. Provider business mailing address

225 MEMORIAL DR STE 1200
BERLIN WI
54923-1243
US

V. Phone/Fax

Practice location:
  • Phone: 920-361-5770
  • Fax: 920-361-5779
Mailing address:
  • Phone: 920-361-5770
  • Fax: 920-361-5779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number99850-030
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1682-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: