Provider Demographics
NPI:1407739063
Name:FRY, DIANE ELIZABETH
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ELIZABETH
Last Name:FRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 N SUSQUEHANNA TRL
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-7766
Mailing Address - Country:US
Mailing Address - Phone:570-374-8381
Mailing Address - Fax:570-372-6000
Practice Address - Street 1:980 N SUSQUEHANNA TRL
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-7766
Practice Address - Country:US
Practice Address - Phone:570-347-8381
Practice Address - Fax:570-372-6000
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-30
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA264278156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician