Provider Demographics
NPI:1922185628
Name:DEICKE, ADAIR LYNNE
Entity Type:Individual
Prefix:MS
First Name:ADAIR
Middle Name:LYNNE
Last Name:DEICKE
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 1:2740 COCONUT BAY LN UNIT 3G
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-3055
Mailing Address - Country:US
Mailing Address - Phone:727-239-9938
Mailing Address - Fax:
Practice Address - Street 1:2740 COCONUT BAY LN UNIT 3G
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-3055
Practice Address - Country:US
Practice Address - Phone:727-239-9938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0941812363L00000X
FL941812363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303680400Medicaid
FL303680400Medicaid
FLE4645Medicare UPIN