Healthcare Provider Details

I. General information

NPI: 1366704686
Provider Name (Legal Business Name): ERICA L FLYNN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W LAKE ST
MELROSE PARK IL
60160-4039
US

IV. Provider business mailing address

3998 FAIR RIDGE DR SUITE # 300
FAIRFAX VA
22033-2921
US

V. Phone/Fax

Practice location:
  • Phone: 708-846-5291
  • Fax:
Mailing address:
  • Phone: 703-295-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041359565
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209010010
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: