Healthcare Provider Details

I. General information

NPI: 1275148488
Provider Name (Legal Business Name): RAECE FLYNT NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 SANDERS ST
ATHENS AL
35611-2459
US

IV. Provider business mailing address

3326 LOGGERS PL SW
DECATUR AL
35603-2116
US

V. Phone/Fax

Practice location:
  • Phone: 256-230-1116
  • Fax:
Mailing address:
  • Phone: 256-541-4443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-152026
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: