MEDICARE: ALYSSA L FREDERICKS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	ATR-001676	AZ

General Provider Information

NPI Number	:	1497222681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA L FREDERICKS

Provider Business Mailing Address
First Line	:	PO BOX 32
Second Line	:
City	:	KYKOTSMOVI
State	:	AZ
Zip	:	86039-0032
Country	:	US
Telephone Number	:	928-514-3402
Fax Number	:

Provider Business Practice Location Address
First Line	:	HWY 264 MILEPOST 388
Second Line	:	UNIT 40
City	:	POLACCA
State	:	AZ
Zip	:	86042
Country	:	US
Telephone Number	:	928-737-0414
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2018
Last Update Date	:	10/26/2018

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Directions to “ ALYSSA L FREDERICKS ” Practice Location

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