Provider Demographics
NPI:1518139021
Name:FREDERICKS, BONITA L (LPN)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:L
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 SUMNER RD
Mailing Address - Street 2:
Mailing Address - City:DARIEN CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14040-9797
Mailing Address - Country:US
Mailing Address - Phone:585-547-9367
Mailing Address - Fax:
Practice Address - Street 1:1177 SUMNER RD
Practice Address - Street 2:
Practice Address - City:DARIEN CENTER
Practice Address - State:NY
Practice Address - Zip Code:14040-9797
Practice Address - Country:US
Practice Address - Phone:585-547-9367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2677331164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02705966Medicaid