MEDICARE: MARIE ELISABETH FREDERICK FNP-C

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	363LF0000X	Family Nurse Practitioner	209.023784	IL
2	363LF0000X	Family Nurse Practitioner	26697	SC

General Provider Information

NPI Number	:	1750051090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE ELISABETH FREDERICK FNP-C

Provider Business Mailing Address
First Line	:	PO BOX 470408
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28247-0408
Country	:	US
Telephone Number	:	704-887-6402
Fax Number	:	704-887-6450

Provider Business Practice Location Address
First Line	:	1057 RED VENTURES DR STE 150
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29707-2518
Country	:	US
Telephone Number	:	803-548-3708
Fax Number	:	704-887-6450

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

Provider Enumeration Date	:	09/17/2021
Last Update Date	:	08/19/2024

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