MEDICARE: SHANDA NICOLE FREDERICK LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	26NP06593200	NJ

General Provider Information

NPI Number	:	1538444989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANDA NICOLE FREDERICK LPN

Provider Business Mailing Address
First Line	:	633 S 19TH ST
Second Line	:	1ST FL
City	:	NEWARK
State	:	NJ
Zip	:	07103-1116
Country	:	US
Telephone Number	:	862-576-7768
Fax Number	:

Provider Business Practice Location Address
First Line	:	633 S 19TH ST
Second Line	:	1ST FL
City	:	NEWARK
State	:	NJ
Zip	:	07103-1116
Country	:	US
Telephone Number	:	862-576-7768
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2011
Last Update Date	:	10/17/2011

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