Provider Demographics
NPI:1366479693
Name:FRYCKLUND, LAURA LEE (NP)
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:LEE
Last Name:FRYCKLUND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:38429 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7009
Mailing Address - Country:US
Mailing Address - Phone:440-269-7488
Mailing Address - Fax:440-946-9208
Practice Address - Street 1:38429 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-7009
Practice Address - Country:US
Practice Address - Phone:440-269-7488
Practice Address - Fax:440-946-9208
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP07766363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHQ36281Medicare UPIN