Provider Demographics
NPI:1194714824
Name:FRY, LUBOV (ARNP)
Entity type:Individual
Prefix:
First Name:LUBOV
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 E CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-9425
Mailing Address - Country:US
Mailing Address - Phone:954-336-1824
Mailing Address - Fax:
Practice Address - Street 1:892 E CHICAGO ST STE C
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2063
Practice Address - Country:US
Practice Address - Phone:517-278-2301
Practice Address - Fax:517-278-2784
Is Sole Proprietor?:No
Enumeration Date:2005-10-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704319901363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P49620Medicare UPIN