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General NPI Number Information
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NPI Number | 1679152664
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Entity Type | Individual
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Provider Name | GLENN H FREDENBURG
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Gender | Male
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Dates
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Enumeration Date | 04/06/2021
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Last Update Date | 04/27/2022
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Provider Practice Location Address
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Address Line | 40 LA RIVIERE DR STE 201
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City | BUFFALO
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State | NY
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Zip | 14202-4344
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Country | US
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Telephone | 518-335-5097
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Fax |
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Provider Business Mailing Address
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Address Line | 9467 STATE ROUTE 9
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City | CHAZY
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State | NY
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Zip | 12921-2043
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Country | US
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Telephone | 518-335-5097
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 101.0134798
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License Number State | VT
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