Provider Demographics
NPI:1821472044
Name:FRY, KATHRYN A (NP-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:FRY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 ONTARIO
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62707-9318
Mailing Address - Country:US
Mailing Address - Phone:178-013-0152
Mailing Address - Fax:872-231-0577
Practice Address - Street 1:3015 ONTARIO
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62707-9318
Practice Address - Country:US
Practice Address - Phone:178-013-0152
Practice Address - Fax:872-231-0577
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2021-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA164096363LF0000X
IL277001424363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily