Provider Demographics
NPI:1629010970
Name:AMADASUN, KELLEY IV
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:AMADASUN
Suffix:IV
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 1:905 GREEN COVE LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75232-1639
Mailing Address - Country:US
Mailing Address - Phone:214-374-6722
Mailing Address - Fax:214-376-3909
Practice Address - Street 1:905 GREEN COVE LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-1639
Practice Address - Country:US
Practice Address - Phone:214-374-6722
Practice Address - Fax:214-376-3909
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide