1275811242 NPI number — MS. AMELIA FRY MS, CCC-SLP, IBCLC

Table of content: MS. AMELIA FRY MS, CCC-SLP, IBCLC (NPI 1275811242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275811242 NPI number — MS. AMELIA FRY MS, CCC-SLP, IBCLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRY
Provider First Name:
AMELIA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, CCC-SLP, IBCLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275811242
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 SE HIBISCUS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34996-3602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-485-4357
Provider Business Mailing Address Fax Number:
772-872-5858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 SE HIBISCUS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34996-3602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-485-4357
Provider Business Practice Location Address Fax Number:
772-872-5858
Provider Enumeration Date:
07/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174N00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: L-111185 . This is a "INTERNATIONAL BOARD OF LACTATION CONSULTANT EXAMINERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004024000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14030798 . This is a "AMERICAN SPEECH AND HEARING ASSOCIATION" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004024000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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