Provider Demographics
NPI:1912786138
Name:FREDERIQUE, NIKERSON
Entity Type:Individual
Prefix:
First Name:NIKERSON
Middle Name:
Last Name:FREDERIQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 EDMUND ST
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-1008
Mailing Address - Country:US
Mailing Address - Phone:401-660-4328
Mailing Address - Fax:
Practice Address - Street 1:74 EDMUND ST
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-1008
Practice Address - Country:US
Practice Address - Phone:401-660-4328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty