Healthcare Provider Details

I. General information

NPI: 1609218007
Provider Name (Legal Business Name): BEVERLY TAYLOR FREDENBURGH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 WASHINGTON AVE
SUFFERN NY
10901-6026
US

IV. Provider business mailing address

286 W LAKE ST
LIBERTY NY
12754-3904
US

V. Phone/Fax

Practice location:
  • Phone: 845-357-4500
  • Fax: 845-357-5039
Mailing address:
  • Phone: 845-866-4181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number273920
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: