MEDICARE: MRS. SUSAN KATHERINE FRADY FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	10059	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083935001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN KATHERINE FRADY FNP

Provider Business Mailing Address
First Line	:	1203 ELM AVE
Second Line	:
City	:	CANON CITY
State	:	CO
Zip	:	81212-4829
Country	:	US
Telephone Number	:	303-981-6221
Fax Number	:

Provider Business Practice Location Address
First Line	:	715 S 9TH ST
Second Line	:
City	:	CANON CITY
State	:	CO
Zip	:	81212-4911
Country	:	US
Telephone Number	:	719-269-8820
Fax Number	:	719-204-0230

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2010
Last Update Date	:	03/29/2016

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