Basic Information
| Provider Information | |||||||||
| NPI: | 1790325843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRYE | ||||||||
| FirstName: | BERNADETTE | ||||||||
| MiddleName: | ANITA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUDACK | ||||||||
| OtherFirstName: | BERNADETTE | ||||||||
| OtherMiddleName: | ANITA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4202 41ST ST W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342052332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412547670 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 41 MALL RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018052332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2020 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | APRN11005348 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | RN2362878 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | APRN11005348 | 01 | FL | STATE LICENSE | OTHER |