Healthcare Provider Details

I. General information

NPI: 1427024454
Provider Name (Legal Business Name): DOUGLAS E FRY CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 AVON RD
NARBERTH PA
19072
US

IV. Provider business mailing address

615 W MAIN ST
LANSDALE PA
19446-2011
US

V. Phone/Fax

Practice location:
  • Phone: 267-263-0657
  • Fax: 267-263-0667
Mailing address:
  • Phone: 610-940-2604
  • Fax: 610-940-2605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN247115L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: