Provider Demographics
NPI:1841064441
Name:FRYSON, LEESHUN OA
Entity type:Individual
Prefix:
First Name:LEESHUN
Middle Name:OA
Last Name:FRYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 LANA CIR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5631
Mailing Address - Country:US
Mailing Address - Phone:850-556-1192
Mailing Address - Fax:
Practice Address - Street 1:3840 LANA CIR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5631
Practice Address - Country:US
Practice Address - Phone:850-556-1192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health