Provider Demographics
NPI:1295233609
Name:FRY, NICOLE (LAT, ATC)
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8749 ORANGE LEAF CT
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-5036
Mailing Address - Country:US
Mailing Address - Phone:970-846-7807
Mailing Address - Fax:
Practice Address - Street 1:17410 COMMERCE PARK BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3500
Practice Address - Country:US
Practice Address - Phone:813-558-1185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL49602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer