Healthcare Provider Details

I. General information

NPI: 1730849829
Provider Name (Legal Business Name): PAULA FLYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W ABRIENDO AVE
PUEBLO CO
81004-1003
US

IV. Provider business mailing address

999 FORTINO BLVD LOT 166
PUEBLO CO
81008-2070
US

V. Phone/Fax

Practice location:
  • Phone: 334-590-2013
  • Fax:
Mailing address:
  • Phone: 334-590-2013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA.0001379
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: