Healthcare Provider Details

I. General information

NPI: 1083935001
Provider Name (Legal Business Name): SUSAN KATHERINE FRADY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 03/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 S 9TH ST
CANON CITY CO
81212-4911
US

IV. Provider business mailing address

1203 ELM AVE
CANON CITY CO
81212-4829
US

V. Phone/Fax

Practice location:
  • Phone: 719-269-8820
  • Fax: 719-204-0230
Mailing address:
  • Phone: 303-981-6221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10059
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: