Healthcare Provider Details

I. General information

NPI: 1245752666
Provider Name (Legal Business Name): REBECCA FREDMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 BRUNN SCHOOL RD STE C
SANTA FE NM
87505-1102
US

IV. Provider business mailing address

404 BRUNN SCHOOL RD STE C
SANTA FE NM
87505-1102
US

V. Phone/Fax

Practice location:
  • Phone: 505-699-4187
  • Fax:
Mailing address:
  • Phone: 505-699-4187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number61681
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: