MEDICARE: FREDERICKSBURG NEPHROLOGY ASSOCIATES, INC.

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	207RN0300X	Nephrology Physician		VA

General Provider Information

NPI Number	:	1861583510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDERICKSBURG NEPHROLOGY ASSOCIATES, INC.

Provider Business Mailing Address
First Line	:	101 PARK HILL DR
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-3357
Country	:	US
Telephone Number	:	540-371-3010
Fax Number	:	540-899-9821

Provider Business Practice Location Address
First Line	:	101 PARK HILL DR
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22401-3357
Country	:	US
Telephone Number	:	540-371-3010
Fax Number	:	540-899-9821

Authorized Official
Title or Position	:	CREDENTIALING SUPERVISOR
Name	:	TAMMY PROVENCHER
Credential	:	PROVENCHER
Telephone Number	:	540-371-3010

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	11/17/2025

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