Basic Information
| Provider Information | |||||||||
| NPI: | 1457536096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDERICKS | ||||||||
| FirstName: | NADIA | ||||||||
| MiddleName: | N | ||||||||
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| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1981 MARCUS AVE | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110421038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127460838 | ||||||||
| FaxNumber: | 5164374167 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 E 68TH ST | ||||||||
| Address2: | GREENBERG PAVILION RM 10-171 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100654870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127460838 | ||||||||
| FaxNumber: | 5164374167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2008 | ||||||||
| LastUpdateDate: | 01/02/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 006352 | NY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 006352 | 01 | NY | LICENSE NUMBER | OTHER |