Provider Demographics
NPI:1558901439
Name:FRY, BOBBI (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BOBBI
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8092 W PARADISE LN APT 1127
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-4984
Mailing Address - Country:US
Mailing Address - Phone:360-581-9977
Mailing Address - Fax:
Practice Address - Street 1:1 W FIRESTORM WAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3216
Practice Address - Country:US
Practice Address - Phone:360-581-9977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZATR-009032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer