Healthcare Provider Details

I. General information

NPI: 1871912766
Provider Name (Legal Business Name): AMANDA MAE FLYNN LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2014
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 PARK AVE
MINNEAPOLIS MN
55404-1136
US

IV. Provider business mailing address

801 PARK AVE
MINNEAPOLIS MN
55404-1136
US

V. Phone/Fax

Practice location:
  • Phone: 612-343-3265
  • Fax: 612-343-3267
Mailing address:
  • Phone: 612-343-3265
  • Fax: 612-343-3267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number22552
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: