Provider Demographics
NPI:1063866457
Name:FREDERIC, RUDY
Entity Type:Individual
Prefix:
First Name:RUDY
Middle Name:
Last Name:FREDERIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 E 16TH ST
Mailing Address - Street 2:APT D5
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-6568
Mailing Address - Country:US
Mailing Address - Phone:347-651-3938
Mailing Address - Fax:
Practice Address - Street 1:633 E 16TH ST
Practice Address - Street 2:APT D5
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-6568
Practice Address - Country:US
Practice Address - Phone:347-651-3938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324616164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse