Provider Demographics
NPI:1386898013
Name:FREDERICKS, GLORIA (CRNP)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:207 N BROAD ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:267-479-4165
Mailing Address - Fax:215-463-3820
Practice Address - Street 1:255 W LANCASTER AVE
Practice Address - Street 2:PAOLI MEDICAL BUILDING 3 SUITE 234
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1763
Practice Address - Country:US
Practice Address - Phone:610-647-4260
Practice Address - Fax:610-647-7430
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2013-01-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PASP007210363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA244176GT6Medicare PIN