Provider Demographics
NPI:1083935001
Name:FRADY, SUSAN KATHERINE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KATHERINE
Last Name:FRADY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-4829
Mailing Address - Country:US
Mailing Address - Phone:303-981-6221
Mailing Address - Fax:
Practice Address - Street 1:715 S 9TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4911
Practice Address - Country:US
Practice Address - Phone:719-269-8820
Practice Address - Fax:719-204-0230
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10059363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60539577Medicaid