Provider Demographics
NPI:1871294447
Name:FREDERIC, MARJORY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARJORY
Middle Name:
Last Name:FREDERIC
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5940 S RAINBOW BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-2507
Mailing Address - Country:US
Mailing Address - Phone:702-854-6853
Mailing Address - Fax:702-758-7315
Practice Address - Street 1:5940 S RAINBOW BLVD STE 400
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2507
Practice Address - Country:US
Practice Address - Phone:702-854-6853
Practice Address - Fax:702-758-7315
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN78446163WC0400X, 163W00000X
NV871409363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse