Healthcare Provider Details

I. General information

NPI: 1821432949
Provider Name (Legal Business Name): AMY FREDERICKS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3819 215TH PL
BAYSIDE NY
11361-2311
US

IV. Provider business mailing address

3819 215TH PL
BAYSIDE NY
11361-2311
US

V. Phone/Fax

Practice location:
  • Phone: 646-315-1505
  • Fax:
Mailing address:
  • Phone: 646-315-1505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number642293
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: