Provider Demographics
NPI:1144734542
Name:FRUCTUOSO, DREMA G (LPN)
Entity type:Individual
Prefix:
First Name:DREMA
Middle Name:G
Last Name:FRUCTUOSO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202-204 EDGECOMBE AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-1102
Mailing Address - Country:US
Mailing Address - Phone:212-690-1900
Mailing Address - Fax:212-690-4097
Practice Address - Street 1:202 EDGECOMBE AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-1102
Practice Address - Country:US
Practice Address - Phone:212-690-1900
Practice Address - Fax:212-690-4097
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196599-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse