=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053483750
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY LYNN ADAMS D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 10/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5722 S FLAMINGO RD #273
-----------------------------------------------------
City | COOPER CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33330-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-609-9001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5722 S FLAMINGO RD #273
-----------------------------------------------------
City | COOPER CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33330-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-609-9001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | OS 9082
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------