Provider Demographics
NPI:1659233419
Name:FREDERICKS, ERIC JAMES (CNA)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JAMES
Last Name:FREDERICKS
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 SE FLEMING ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97366-9692
Mailing Address - Country:US
Mailing Address - Phone:707-880-2364
Mailing Address - Fax:
Practice Address - Street 1:835 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4802
Practice Address - Country:US
Practice Address - Phone:541-265-5356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10046143376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide