Provider Demographics
NPI:1770021271
Name:FRICKE, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:FRICKE
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 1:7520 LARWINN DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5221
Mailing Address - Country:US
Mailing Address - Phone:815-218-4869
Mailing Address - Fax:
Practice Address - Street 1:7520 LARWINN DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5221
Practice Address - Country:US
Practice Address - Phone:815-218-4869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041213739163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse