Healthcare Provider Details

I. General information

NPI: 1386898013
Provider Name (Legal Business Name): GLORIA FREDERICKS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W LANCASTER AVE PAOLI MEDICAL BUILDING 3 SUITE 234
PAOLI PA
19301-1763
US

IV. Provider business mailing address

207 N BROAD ST 3RD FLOOR
PHILADELPHIA PA
19107-1500
US

V. Phone/Fax

Practice location:
  • Phone: 610-647-4260
  • Fax: 610-647-7430
Mailing address:
  • Phone: 267-479-4165
  • Fax: 215-463-3820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP007210
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: