Provider Demographics
NPI:1861128662
Name:FREDRICK, DEAUNDRIA (CPT)
Entity type:Individual
Prefix:
First Name:DEAUNDRIA
Middle Name:
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 CALICO CT
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29172-2608
Mailing Address - Country:US
Mailing Address - Phone:803-383-5818
Mailing Address - Fax:
Practice Address - Street 1:223 CALICO CT
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29172-2608
Practice Address - Country:US
Practice Address - Phone:803-383-5818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000OtherN/A