Healthcare Provider Details

I. General information

NPI: 1174980320
Provider Name (Legal Business Name): KERRY FLYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

2349 APACHE ST
MENDOTA HEIGHTS MN
55120-1605
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-6000
  • Fax:
Mailing address:
  • Phone: 612-867-1715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR-193978-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: