Provider Demographics
NPI:1215267562
Name:FRY, DEBRA KAY (STNA)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:KAY
Last Name:FRY
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-7037
Mailing Address - Country:US
Mailing Address - Phone:397-912-9047
Mailing Address - Fax:937-912-9048
Practice Address - Street 1:1185 FOREST DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-7037
Practice Address - Country:US
Practice Address - Phone:937-912-9047
Practice Address - Fax:937-912-9048
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-09
Last Update Date:2010-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400956310809172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker