Provider Demographics
NPI:1285282566
Name:FRY, NICOLE FABIANO (DNP, FNP-C)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:FABIANO
Last Name:FRY
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:FABIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:7265 DUSTY TRL
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8019
Mailing Address - Country:US
Mailing Address - Phone:815-871-3144
Mailing Address - Fax:
Practice Address - Street 1:1501 10TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5044
Practice Address - Country:US
Practice Address - Phone:575-434-2960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM61912163W00000X, 363LF0000X
IL041437418163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse