Healthcare Provider Details

I. General information

NPI: 1245540459
Provider Name (Legal Business Name): MALLORY JEAN FLYNN RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3288 MOANALUA RD
HONOLULU HI
96819-1469
US

IV. Provider business mailing address

159 MOOKUA ST
KAILUA HI
96734-5842
US

V. Phone/Fax

Practice location:
  • Phone: 808-432-0000
  • Fax:
Mailing address:
  • Phone: 516-524-1052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number014409
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: