Provider Demographics
NPI:1033922059
Name:FRY, MADELINE X (MHA, NHA)
Entity type:Individual
Prefix:MS
First Name:MADELINE
Middle Name:
Last Name:FRY
Suffix:X
Gender:F
Credentials:MHA, NHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11693 SAN VICENTE BLVD # 143
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5105
Mailing Address - Country:US
Mailing Address - Phone:310-405-5758
Mailing Address - Fax:
Practice Address - Street 1:941 1/2 HILGARD AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3032
Practice Address - Country:US
Practice Address - Phone:310-405-5758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5356376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator