Provider Demographics
NPI:1538444989
Name:FREDERICK, SHANDA NICOLE (LPN)
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:NICOLE
Last Name:FREDERICK
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 1:633 S 19TH ST
Mailing Address - Street 2:1ST FL
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-1116
Mailing Address - Country:US
Mailing Address - Phone:862-576-7768
Mailing Address - Fax:
Practice Address - Street 1:633 S 19TH ST
Practice Address - Street 2:1ST FL
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-1116
Practice Address - Country:US
Practice Address - Phone:862-576-7768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP06593200164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse