Provider Demographics
NPI:1366402224
Name:FRY, JUDY LYNN (CNM)
Entity type:Individual
Prefix:MS
First Name:JUDY
Middle Name:LYNN
Last Name:FRY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:803-435-5270
Mailing Address - Fax:803-433-0154
Practice Address - Street 1:50 E HOSPITAL ST
Practice Address - Street 2:SUITE 4A
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3149
Practice Address - Country:US
Practice Address - Phone:803-433-0797
Practice Address - Fax:803-433-0896
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2017-09-25
Deactivation Date:2017-08-31
Deactivation Code:
Reactivation Date:2017-09-25
Provider Licenses
StateLicense IDTaxonomies
SCAPN2297176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMW0100Medicaid
SCMW0100Medicaid