Healthcare Provider Details

I. General information

NPI: 1306166905
Provider Name (Legal Business Name): COURTNEY NICOLE FLYNN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 06/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 E SHORE DR STE 100
EAGLE ID
83616-5410
US

IV. Provider business mailing address

4082 N BRYCE CANYON AVE
MERIDIAN ID
83646-4958
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-3443
  • Fax: 208-938-3553
Mailing address:
  • Phone: 410-458-1712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-971A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: