Provider Demographics
NPI:1679824023
Name:FRIES, MARTHA JANE
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:JANE
Last Name:FRIES
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 1:4513 BISHOPS GATE RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-1515
Mailing Address - Country:US
Mailing Address - Phone:330-455-0666
Mailing Address - Fax:
Practice Address - Street 1:4513 BISHOPS GATE RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-1515
Practice Address - Country:US
Practice Address - Phone:330-455-0666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN..039933164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse