Provider Demographics
NPI:1811930894
Name:FRYE, SUSAN MARILYN (RN, PHN, GNP,C)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARILYN
Last Name:FRYE
Suffix:
Gender:F
Credentials:RN, PHN, GNP,C
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MARILYN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, PHN, GNP,C
Mailing Address - Street 1:3583 GRANADA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-4144
Mailing Address - Country:US
Mailing Address - Phone:619-688-0774
Mailing Address - Fax:
Practice Address - Street 1:3440 HOLLYWOOD BLVD
Practice Address - Street 2:SUITE 460
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6927
Practice Address - Country:US
Practice Address - Phone:866-986-2263
Practice Address - Fax:866-968-6339
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA399028363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology