Provider Demographics
NPI:1508286949
Name:FREDERICK, ENA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:ENA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:ENA
Other - Middle Name:
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:13 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-6003
Mailing Address - Country:US
Mailing Address - Phone:516-823-0739
Mailing Address - Fax:
Practice Address - Street 1:13 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6003
Practice Address - Country:US
Practice Address - Phone:516-823-0739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257421-1163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health