Provider Demographics
NPI:1518720861
Name:ADOLPHE, MIRLEY FREDLEEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MIRLEY
Middle Name:FREDLEEN
Last Name:ADOLPHE
Suffix:
Gender:F
Credentials:PA-C
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 1978
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1978
Mailing Address - Country:US
Mailing Address - Phone:410-749-1015
Mailing Address - Fax:410-749-0654
Practice Address - Street 1:1665 WOODBROOKE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-8502
Practice Address - Country:US
Practice Address - Phone:410-546-6650
Practice Address - Fax:410-546-2656
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid