Provider Demographics
NPI:1275904922
Name:FEDRICH, DESIREE (NP)
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:
Last Name:FEDRICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STONY BROOK CANCER CTR
Mailing Address - Street 2:9445 SUNY 9460
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-9460
Mailing Address - Country:US
Mailing Address - Phone:631-638-0693
Mailing Address - Fax:631-638-0660
Practice Address - Street 1:SUNY STONY BROOK HOSPITAL
Practice Address - Street 2:101 NICHOLS ROAD
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-638-0693
Practice Address - Fax:631-638-0660
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306194-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health