Provider Demographics
NPI:1447930623
Name:FREDERICKS, EMILY MARIA (CPNP)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:MARIA
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 STERLING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-7752
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2230
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014132A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics