Provider Demographics
NPI:1265922926
Name:FREDERICK, HERSHA (FNP)
Entity type:Individual
Prefix:
First Name:HERSHA
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 NEW YORK AVE
Mailing Address - Street 2:6G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213
Mailing Address - Country:US
Mailing Address - Phone:201-443-6163
Mailing Address - Fax:973-643-5230
Practice Address - Street 1:363 NEW YORK AVE APT 6G
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-4252
Practice Address - Country:US
Practice Address - Phone:201-443-6163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340619363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty