Provider Demographics
NPI:1790211100
Name:DUKE, FREDA
Entity Type:Individual
Prefix:MRS
First Name:FREDA
Middle Name:
Last Name:DUKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33404 VINE ST
Mailing Address - Street 2:210
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-3436
Mailing Address - Country:US
Mailing Address - Phone:216-780-6025
Mailing Address - Fax:
Practice Address - Street 1:33404 VINE ST
Practice Address - Street 2:210
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-3436
Practice Address - Country:US
Practice Address - Phone:216-780-6025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0065783Medicaid