Healthcare Provider Details

I. General information

NPI: 1811930894
Provider Name (Legal Business Name): SUSAN MARILYN FRYE RN, PHN, GNP,C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN MARILYN JOHNSON RN, PHN, GNP,C

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 HOLLYWOOD BLVD SUITE 460
HOLLYWOOD FL
33021-6927
US

IV. Provider business mailing address

3583 GRANADA AVE
SAN DIEGO CA
92104-4144
US

V. Phone/Fax

Practice location:
  • Phone: 866-986-2263
  • Fax: 866-968-6339
Mailing address:
  • Phone: 619-688-0774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number399028
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: