Provider Demographics
NPI:1720675861
Name:FREDERICKS, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 WRISTON AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-2530
Mailing Address - Country:US
Mailing Address - Phone:012-651-1024
Mailing Address - Fax:
Practice Address - Street 1:148 WRISTON AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-2530
Practice Address - Country:US
Practice Address - Phone:012-651-1024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN31387163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse