Provider Demographics
NPI:1457833527
Name:FREDERICK, NICOLE MARIE (LAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 FULTON ST RM 208
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-2538
Mailing Address - Country:US
Mailing Address - Phone:212-513-0437
Mailing Address - Fax:
Practice Address - Street 1:139 FULTON ST RM 208
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2538
Practice Address - Country:US
Practice Address - Phone:212-513-0437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006331171100000X
NY6331171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist