Provider Demographics
NPI:1407303415
Name:FREDERICK, SHARA JOANNE (CM,LM,MS)
Entity Type:Individual
Prefix:MS
First Name:SHARA
Middle Name:JOANNE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:CM,LM,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502A 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4660
Mailing Address - Country:US
Mailing Address - Phone:718-499-3636
Mailing Address - Fax:
Practice Address - Street 1:506 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3609
Practice Address - Country:US
Practice Address - Phone:718-499-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001751176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001751Medicaid