Provider Demographics
NPI:1356500557
Name:FRY, SHANNON (LAC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:121 S REXFORD DR
Mailing Address - Street 2:#8
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3316
Mailing Address - Country:US
Mailing Address - Phone:310-927-2595
Mailing Address - Fax:310-858-1669
Practice Address - Street 1:10524 W PICO BLVD
Practice Address - Street 2:#216
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-2346
Practice Address - Country:US
Practice Address - Phone:310-927-2595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7866171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist