Provider Demographics
NPI:1447731302
Name:FREDERICK, REGINA M (NP)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:M
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
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Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11143 PARKVIEW PLAZA DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1728
Practice Address - Country:US
Practice Address - Phone:260-266-8820
Practice Address - Fax:260-266-8829
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71008494A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner