Provider Demographics
NPI:1063716769
Name:FREDERIC, NANCY (NP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:FREDERIC
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 CRESTMONT RD
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1626
Mailing Address - Country:US
Mailing Address - Phone:973-325-0805
Mailing Address - Fax:
Practice Address - Street 1:75 CRESTMONT RD
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1626
Practice Address - Country:US
Practice Address - Phone:973-325-0805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY581305163W00000X
NJ26NR17113600163W00000X
NY430774363LA2100X
NJ26NJ00512000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care