1811930894 NPI number — MS. SUSAN MARILYN FRYE RN, PHN, GNP,C

Table of content: MS. SUSAN MARILYN FRYE RN, PHN, GNP,C (NPI 1811930894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811930894 NPI number — MS. SUSAN MARILYN FRYE RN, PHN, GNP,C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRYE
Provider First Name:
SUSAN
Provider Middle Name:
MARILYN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN, PHN, GNP,C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
SUSAN
Provider Other Middle Name:
MARILYN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, PHN, GNP,C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811930894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3583 GRANADA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92104-4144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-688-0774
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3440 HOLLYWOOD BLVD
Provider Second Line Business Practice Location Address:
SUITE 460
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-6927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-986-2263
Provider Business Practice Location Address Fax Number:
866-968-6339
Provider Enumeration Date:
06/14/2006

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: 363LG0600X , with the licence number:  399028 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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