Provider Demographics
NPI:1992216758
Name:FREDERICK, STEPHANIE GRACE (CRNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GRACE
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 CHEW ST STE 202
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18102-3434
Mailing Address - Country:US
Mailing Address - Phone:610-776-4767
Mailing Address - Fax:610-606-4475
Practice Address - Street 1:450 CHEW ST STE 202
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102-3434
Practice Address - Country:US
Practice Address - Phone:610-776-4767
Practice Address - Fax:610-606-4475
Is Sole Proprietor?:No
Enumeration Date:2017-10-19
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017998363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily