Healthcare Provider Details

I. General information

NPI: 1205523255
Provider Name (Legal Business Name): ANDREA FREDERIC REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2023
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 AVON ST
PHILADELPHIA PA
19116-3208
US

IV. Provider business mailing address

320 AVON ST
PHILADELPHIA PA
19116-3208
US

V. Phone/Fax

Practice location:
  • Phone: 718-340-8482
  • Fax:
Mailing address:
  • Phone: 718-340-8482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN751098
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN751098
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: