MEDICARE: MRS. MARTHA JANE FRIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN..039933	OH

General Provider Information

NPI Number	:	1679824023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARTHA JANE FRIES

Provider Business Mailing Address
First Line	:	4513 BISHOPS GATE RD NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-1515
Country	:	US
Telephone Number	:	330-455-0666
Fax Number	:

Provider Business Practice Location Address
First Line	:	4513 BISHOPS GATE RD NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-1515
Country	:	US
Telephone Number	:	330-455-0666
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2012
Last Update Date	:	09/25/2012

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