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General NPI Number Information
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NPI Number | 1104749068
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Entity Type | Individual
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Provider Name | KIM FREDRICKS PMHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 07/30/2026
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Last Update Date | 07/30/2026
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Provider Practice Location Address
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Address Line | 1200 W GRANADA BLVD STE 4
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City | ORMOND BEACH
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State | FL
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Zip | 32174-8157
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Country | US
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Telephone | 386-983-4147
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 W GRANADA BLVD STE 4
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City | ORMOND BEACH
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State | FL
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Zip | 32174-8157
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Country | US
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Telephone |
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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 | 2084P0005X
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Taxonomy Name | Neurodevelopmental Disabilities Physician
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License Number | RN9508898
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | RN9508898
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number | RN9508898
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 2084P0805X
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Taxonomy Name | Geriatric Psychiatry Physician
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License Number | RN9508898
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License Number State | FL
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Taxonomy #5
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Taxonomy Code | 2084B0040X
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Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
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License Number | RN9508898
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License Number State | FL
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