Provider Demographics
NPI:1508519224
Name:LIM, ADELYN HEAVIN
Entity Type:Individual
Prefix:
First Name:ADELYN
Middle Name:HEAVIN
Last Name:LIM
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 1:4852 EISENHOWER AVE UNIT 238
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7333
Mailing Address - Country:US
Mailing Address - Phone:303-718-6245
Mailing Address - Fax:
Practice Address - Street 1:4852 EISENHOWER AVE UNIT 238
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-7333
Practice Address - Country:US
Practice Address - Phone:303-718-6245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0002101452164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program