Provider Demographics
NPI:1326546862
Name:FREDERICKS, STEPHANIE GRACE DIBBLE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GRACE DIBBLE
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:GRACE
Other - Last Name:DIBBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1336 PECK LANE
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410
Mailing Address - Country:US
Mailing Address - Phone:203-233-4658
Mailing Address - Fax:
Practice Address - Street 1:56 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1253
Practice Address - Country:US
Practice Address - Phone:203-709-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant