Provider Demographics
NPI:1922839448
Name:FREDERICK, AMANDA (NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:NP
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 587
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-0587
Mailing Address - Country:US
Mailing Address - Phone:830-672-9508
Mailing Address - Fax:830-670-3093
Practice Address - Street 1:1110 N SARAH DEWITT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3311
Practice Address - Country:US
Practice Address - Phone:830-672-8502
Practice Address - Fax:830-541-5557
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX785626163W00000X
TX1084549363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse