Provider Demographics
NPI:1659125730
Name:FRY, MELISSA SUE (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:FRY
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 WATER ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-1749
Mailing Address - Country:US
Mailing Address - Phone:724-840-1428
Mailing Address - Fax:
Practice Address - Street 1:239 COLONNADE BLVD
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2668
Practice Address - Country:US
Practice Address - Phone:724-840-1428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003129133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered