Healthcare Provider Details

I. General information

NPI: 1558709964
Provider Name (Legal Business Name): KELLY A FLYNN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 PRAIRIE ST SUITE 2600
NORTON SHORES MI
49444-7840
US

IV. Provider business mailing address

PO BOX 1848
MUSKEGON MI
49443-1848
US

V. Phone/Fax

Practice location:
  • Phone: 231-727-7900
  • Fax: 231-727-7914
Mailing address:
  • Phone: 231-727-4444
  • Fax: 231-728-4789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5101020666
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5106020666
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: