Healthcare Provider Details

I. General information

NPI: 1275811242
Provider Name (Legal Business Name): AMELIA FRY MS, CCC-SLP, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 04/06/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 SE HIBISCUS AVE
STUART FL
34996-3602
US

IV. Provider business mailing address

615 SE HIBISCUS AVE
STUART FL
34996-3602
US

V. Phone/Fax

Practice location:
  • Phone: 772-485-4357
  • Fax: 772-872-5858
Mailing address:
  • Phone: 772-485-4357
  • Fax: 772-872-5858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: