Provider Demographics
NPI:1568886307
Name:FREDETTE, MARY (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FREDETTE
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 1:126 WOODLOT RD
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-1939
Mailing Address - Country:US
Mailing Address - Phone:631-294-3555
Mailing Address - Fax:
Practice Address - Street 1:126 WOODLOT RD
Practice Address - Street 2:
Practice Address - City:RIDGE
Practice Address - State:NY
Practice Address - Zip Code:11961-1939
Practice Address - Country:US
Practice Address - Phone:631-294-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134976-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse