Healthcare Provider Details

I. General information

NPI: 1285369561
Provider Name (Legal Business Name): FLY FAMILY HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 SAINT MARYS AVE
SIDNEY OH
45365-1359
US

IV. Provider business mailing address

829 SAINT MARYS AVE
SIDNEY OH
45365-1359
US

V. Phone/Fax

Practice location:
  • Phone: 937-606-4275
  • Fax:
Mailing address:
  • Phone: 937-606-4275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AL BERRY
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 323-676-1281