Provider Demographics
NPI:1083818991
Name:FREDRICKSON, SUSAN ANTHONY (RN, MSN, CS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANTHONY
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:RN, MSN, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23-25 BAY STATE COURT
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631
Mailing Address - Country:US
Mailing Address - Phone:508-240-7964
Mailing Address - Fax:508-240-5448
Practice Address - Street 1:23-25 BAY STATE COURT
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631
Practice Address - Country:US
Practice Address - Phone:508-240-7964
Practice Address - Fax:508-240-5448
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA277918364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult