Provider Demographics
NPI:1558983320
Name:FRY, MALORIE NICOLE (MS, RD)
Entity Type:Individual
Prefix:
First Name:MALORIE
Middle Name:NICOLE
Last Name:FRY
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3429 HIBISCUS DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7713
Mailing Address - Country:US
Mailing Address - Phone:239-464-6133
Mailing Address - Fax:
Practice Address - Street 1:13300 S CLEVELAND AVE STE 23
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3877
Practice Address - Country:US
Practice Address - Phone:239-464-6133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86099419133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered