Provider Demographics
NPI:1134221286
Name:FRY, NANCY JOYCE (OD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:JOYCE
Last Name:FRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N 2ND ST
Mailing Address - Street 2:STE C
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-1135
Mailing Address - Country:US
Mailing Address - Phone:816-230-5321
Mailing Address - Fax:816-230-5321
Practice Address - Street 1:201 N 2ND ST
Practice Address - Street 2:STE C
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-1135
Practice Address - Country:US
Practice Address - Phone:816-230-5321
Practice Address - Fax:816-230-5321
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02487152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO09320013OtherBLUE CROSS BLUE SHIELD
MO11269OtherCOVENTRY
MO0001945BMedicare ID - Type Unspecified