Provider Demographics
NPI:1366968109
Name:FRYER, SHANEKA NICOLE
Entity type:Individual
Prefix:
First Name:SHANEKA
Middle Name:NICOLE
Last Name:FRYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:683 BELLAIR CT
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446-1084
Mailing Address - Country:US
Mailing Address - Phone:330-553-9906
Mailing Address - Fax:
Practice Address - Street 1:26 KATHERINE ST
Practice Address - Street 2:
Practice Address - City:STRUTHERS
Practice Address - State:OH
Practice Address - Zip Code:44471-2101
Practice Address - Country:US
Practice Address - Phone:234-806-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
OH251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0213833Medicaid