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General NPI Number Information
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NPI Number | 1053645317
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Entity Type | Individual
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Provider Name | BROOKE LEIGH FREDRICKSON LRD, CSG
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Gender | Female
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Dates
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Enumeration Date | 09/18/2009
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Last Update Date | 09/18/2009
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Provider Practice Location Address
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Address Line | 1200 ROBERTS AVE NE
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City | COOPERSTOWN
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State | ND
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Zip | 58425-7101
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Country | US
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Telephone | 701-797-2221
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Fax |
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Provider Business Mailing Address
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Address Line | 80 COUNTY ROAD 19
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City | COOPERSTOWN
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State | ND
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Zip | 58425-9168
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Country | US
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Telephone | 701-361-7154
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 669
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License Number State | ND
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