Provider Demographics
NPI:1265951149
Name:FREDRICK, GLORIA OKAONYE II (RN)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:OKAONYE
Last Name:FREDRICK
Suffix:II
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11606 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1748
Mailing Address - Country:US
Mailing Address - Phone:718-215-1952
Mailing Address - Fax:
Practice Address - Street 1:11606 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1748
Practice Address - Country:US
Practice Address - Phone:718-215-1952
Practice Address - Fax:718-441-3701
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY456741163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1639694904Medicaid