Provider Demographics
NPI:1336978576
Name:FRY, STEPHANIE (RN, RD, LDN, CDCES)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:RN, RD, LDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9646
Mailing Address - Fax:239-343-9681
Practice Address - Street 1:632 DEL PRADO BLVD N
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2278
Practice Address - Country:US
Practice Address - Phone:239-343-9646
Practice Address - Fax:239-343-9681
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86343660133V00000X
FL9563454163WD0400X
FLND12759133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL125199100Medicaid