Basic Information
| Provider Information | |||||||||
| NPI: | 1891218418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRY | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 242 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549355145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209330686 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 115 E ARNDT ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549352461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209237040 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2017 | ||||||||
| LastUpdateDate: | 07/25/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 6117-26 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.