Healthcare Provider Details

I. General information

NPI: 1477109171
Provider Name (Legal Business Name): MARY ELISE FLYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2019
Last Update Date: 08/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 KING ST
NORTHAMPTON MA
01060-3234
US

IV. Provider business mailing address

PO BOX 175
WENDELL MA
01379-0175
US

V. Phone/Fax

Practice location:
  • Phone: 413-665-8717
  • Fax:
Mailing address:
  • Phone: 978-501-6795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: