Healthcare Provider Details

I. General information

NPI: 1215627708
Provider Name (Legal Business Name): SHELLEY RENEE FLYNN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 05/09/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29229 CENTRAL AVE # 33
LAKE ELSINORE CA
92532-2248
US

IV. Provider business mailing address

32295 MISSION TRL STE R8 #255
LAKE ELSINORE CA
92530-2306
US

V. Phone/Fax

Practice location:
  • Phone: 951-268-9023
  • Fax:
Mailing address:
  • Phone: 909-904-2146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number568949
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: