Provider Demographics
NPI:1679569826
Name:FREDRICK, KAREN J (RN, WHNP, MSN, NP-C)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:J
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:RN, WHNP, MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 39TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1969
Mailing Address - Country:US
Mailing Address - Phone:262-653-4444
Mailing Address - Fax:262-925-0440
Practice Address - Street 1:4303 39TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1969
Practice Address - Country:US
Practice Address - Phone:622-653-4444
Practice Address - Fax:262-925-0440
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI78408-030163W00000X
WI4412-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43949100Medicaid
WI1679569826Medicaid