Provider Demographics
NPI:1649294638
Name:FRY, N. JOEL
Entity type:Individual
Prefix:
First Name:N. JOEL
Middle Name:
Last Name:FRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5415 NW 88TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2950
Mailing Address - Country:US
Mailing Address - Phone:515-727-1338
Mailing Address - Fax:515-727-1340
Practice Address - Street 1:5415 NW 88TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-2950
Practice Address - Country:US
Practice Address - Phone:515-727-1338
Practice Address - Fax:515-727-1340
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA057131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA10346OtherWELLMARK PROVIDER NUMBER