Provider Demographics
NPI:1417739988
Name:FRYER, CANDICE L
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:L
Last Name:FRYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E 110TH ST APT 4W
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3051
Mailing Address - Country:US
Mailing Address - Phone:917-763-7022
Mailing Address - Fax:
Practice Address - Street 1:305 E 110TH ST APT 4W
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-3051
Practice Address - Country:US
Practice Address - Phone:917-763-7022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122667174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty