Provider Demographics
NPI:1881462687
Name:SNODDERLY, ADAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:SNODDERLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 ALABAMA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4405
Mailing Address - Country:US
Mailing Address - Phone:260-414-6750
Mailing Address - Fax:
Practice Address - Street 1:2131 ALABAMA AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4405
Practice Address - Country:US
Practice Address - Phone:260-414-6750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28248088A163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice