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General NPI Number Information
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NPI Number | 1982335022
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Entity Type | Individual
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Provider Name | SHANNON DANIELLE FRY
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Gender | Female
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Dates
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Enumeration Date | 06/20/2022
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Last Update Date | 12/30/2024
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Provider Practice Location Address
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Address Line | 5789 CORDOVA RD
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City | ERIE
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State | IL
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Zip | 61250-9740
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Country | US
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Telephone | 863-221-2351
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Fax |
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Provider Business Mailing Address
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Address Line | 5789 CORDOVA RD
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City | ERIE
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State | IL
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Zip | 61250-9740
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Country | US
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Telephone | 863-221-2351
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0000X
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Taxonomy Name | Pain Management Registered Nurse
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License Number | 209.025648
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | A169408
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License Number State | IA
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Taxonomy #3
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 209.025648
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License Number State | IL
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