Provider Demographics
NPI:1932406444
Name:FEDELICIO, JOANNE SAN JUAN (MSN RN)
Entity type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:SAN JUAN
Last Name:FEDELICIO
Suffix:
Gender:F
Credentials:MSN RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 WOODWARD AVE
Mailing Address - Street 2:APT 2L
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1357
Mailing Address - Country:US
Mailing Address - Phone:347-689-4420
Mailing Address - Fax:
Practice Address - Street 1:376 WOODWARD AVE
Practice Address - Street 2:APT 2L
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1357
Practice Address - Country:US
Practice Address - Phone:347-689-4420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY558454163W00000X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency