Provider Demographics
NPI:1386318269
Name:FREDERICKS, REBECCA ELIZABETH (FNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:E
Other - Last Name:PEASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:35 LAUREL COVE RD
Mailing Address - Street 2:
Mailing Address - City:EAST HADDAM
Mailing Address - State:CT
Mailing Address - Zip Code:06423-1238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:372 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-5415
Practice Address - Country:US
Practice Address - Phone:860-887-5970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.009804363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily