Provider Demographics
NPI:1861554818
Name:FREDO, NANCY J (CNM)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:FREDO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3488
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:936-568-8425
Mailing Address - Fax:936-568-8570
Practice Address - Street 1:1108 SOUTH ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75964-5986
Practice Address - Country:US
Practice Address - Phone:936-560-3097
Practice Address - Fax:936-462-8080
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX599046367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130597107Medicaid
TX130597107Medicaid