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General NPI Number Information
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NPI Number | 1932533924
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Entity Type | Individual
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Provider Name | LISA GAY FREDRICKSON FNP
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Gender | Female
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Dates
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Enumeration Date | 08/26/2013
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Last Update Date | 11/18/2023
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Provider Practice Location Address
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Address Line | 205 SOUTH ST
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City | FORT BRAGG
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State | CA
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Zip | 95437-5540
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Country | US
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Telephone | 707-961-1251
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Fax |
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Provider Business Mailing Address
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Address Line | 860 E LAUREL ST
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City | FORT BRAGG
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State | CA
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Zip | 95437-3817
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Country | US
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Telephone | 707-972-0884
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 95026356
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 806740
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License Number State | CA
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