Provider Demographics
NPI:1447500905
Name:BACK, FRADI J (RN)
Entity type:Individual
Prefix:
First Name:FRADI
Middle Name:J
Last Name:BACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-1825
Mailing Address - Country:US
Mailing Address - Phone:732-616-3838
Mailing Address - Fax:732-905-5591
Practice Address - Street 1:325 11TH ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-1825
Practice Address - Country:US
Practice Address - Phone:732-616-3838
Practice Address - Fax:732-905-5591
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY659045163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse