Provider Demographics
NPI:1720371800
Name:FLY, KATHRYN LYNN (AP)
Entity Type:Individual
Prefix:MISS
First Name:KATHRYN
Middle Name:LYNN
Last Name:FLY
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 SW 29TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33315-2905
Mailing Address - Country:US
Mailing Address - Phone:954-673-2736
Mailing Address - Fax:
Practice Address - Street 1:931 SW 29TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33315-2905
Practice Address - Country:US
Practice Address - Phone:954-673-2736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 2979171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist