Provider Demographics
NPI:1871035162
Name:FREDERICKS, JOHN M JR (LPN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:FREDERICKS
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:M
Other - Last Name:FREDERICKS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:2975 RTE 9
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:NY
Mailing Address - Zip Code:10516
Mailing Address - Country:US
Mailing Address - Phone:646-925-4469
Mailing Address - Fax:
Practice Address - Street 1:2975 RTE 9
Practice Address - Street 2:COLD SPRING
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10516
Practice Address - Country:US
Practice Address - Phone:646-925-4469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217537-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse