Provider Demographics
NPI:1316787583
Name:FRY, TIFFANY MARIE (FNP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:FRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10233 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85194-7568
Mailing Address - Country:US
Mailing Address - Phone:414-544-1512
Mailing Address - Fax:
Practice Address - Street 1:1727 E PECOS RD APT 2054
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1868
Practice Address - Country:US
Practice Address - Phone:414-544-1512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF05240559363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care