Provider Demographics
NPI:1982335022
Name:FRY, SHANNON DANIELLE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DANIELLE
Last Name:FRY
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 1:5789 CORDOVA RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:IL
Mailing Address - Zip Code:61250-9740
Mailing Address - Country:US
Mailing Address - Phone:863-221-2351
Mailing Address - Fax:
Practice Address - Street 1:5789 CORDOVA RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:IL
Practice Address - Zip Code:61250-9740
Practice Address - Country:US
Practice Address - Phone:863-221-2351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.025648163WP0000X, 208100000X
IAA169408363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No163WP0000XNursing Service ProvidersRegistered NursePain Management
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily