Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | OC.000024 | OH |
NPI | 1679047609 |
---|---|
Provider Name | Melissa Frederick |
First Address | Weldon Spring, MO 63304-7890 |
Second Address | Cleveland, OH 44115-2001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/01/2019 |
Last Update Date | 12/01/2019 |