Provider Demographics
NPI:1891599437
Name:FREDENBURG, MAGGIE ADORA
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:ADORA
Last Name:FREDENBURG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-4817
Mailing Address - Country:US
Mailing Address - Phone:315-804-7397
Mailing Address - Fax:
Practice Address - Street 1:159 WEST FIRST STREET
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-315-3429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist