MEDICARE: ELAINE M FREDRICKSON APRN

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	207Q00000X	Family Medicine Physician	ARNP9186537	FL
2	363LF0000X	Family Nurse Practitioner	3014562	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972564433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELAINE M FREDRICKSON APRN

Provider Business Mailing Address
First Line	:	5336 ANN ARBOR DR
Second Line	:
City	:	BOKEELIA
State	:	FL
Zip	:	33922-3016
Country	:	US
Telephone Number	:	561-248-9297
Fax Number	:	561-248-9297

Provider Business Practice Location Address
First Line	:	4700 N CONGRESS AVE
Second Line	:	STE 103
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-3284
Country	:	US
Telephone Number	:	561-255-3131
Fax Number	:	855-346-3451

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

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	05/23/2022

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Directions to “ ELAINE M FREDRICKSON APRN” Practice Location

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