Provider Demographics
NPI:1508460577
Name:FRYE, SHANNON LYNN (D-PT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNN
Last Name:FRYE
Suffix:
Gender:F
Credentials:D-PT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:LYNN
Other - Last Name:CARNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:D-PT
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-7822
Practice Address - Fax:920-433-3651
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15291-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist