Healthcare Provider Details

I. General information

NPI: 1194780288
Provider Name (Legal Business Name): ANITA LYNN FREDERICK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29250 COUNTY HWY E
MASON WI
54856-1072
US

IV. Provider business mailing address

4736 WAISANEN RD
EMBARRASS MN
55732-8346
US

V. Phone/Fax

Practice location:
  • Phone: 715-765-4791
  • Fax:
Mailing address:
  • Phone: 218-780-3164
  • Fax: 218-984-3603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number160826-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: