Provider Demographics
NPI:1578184560
Name:FRY, HEATHER ELAINE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELAINE
Last Name:FRY
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 1:4101 PERIMETER CENTER DR STE 250
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2309
Mailing Address - Country:US
Mailing Address - Phone:405-226-0843
Mailing Address - Fax:
Practice Address - Street 1:1908 E GORE BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-6129
Practice Address - Country:US
Practice Address - Phone:405-593-3944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK105923363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care