Provider Demographics
NPI:1871223404
Name:JIMENEZ, FREDERICO (LPN)
Entity Type:Individual
Prefix:
First Name:FREDERICO
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 COLUMBIA ST APT 4A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-2610
Mailing Address - Country:US
Mailing Address - Phone:646-956-9172
Mailing Address - Fax:
Practice Address - Street 1:8 E 3RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-8908
Practice Address - Country:US
Practice Address - Phone:212-620-0340
Practice Address - Fax:212-533-8400
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336371164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY132602882Medicaid