Healthcare Provider Details

I. General information

NPI: 1023401148
Provider Name (Legal Business Name): SHANNON MICHELLE FLYNN ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 EDGEMONT BLVD
ALAMOSA CO
81101-2320
US

IV. Provider business mailing address

42931 SAXONY RD
CANTON MI
48187-2337
US

V. Phone/Fax

Practice location:
  • Phone: 719-587-7011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.0001767
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: