Healthcare Provider Details

I. General information

NPI: 1497840003
Provider Name (Legal Business Name): VICKI LORRAINE FLYNN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VICKI LORRAINE ADEMA CRNA

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 SHELDON STREET
ST. PAUL MN
55108
US

IV. Provider business mailing address

15490 293RD AVENUE
ZIMMERMAN MN
55398
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-3091
  • Fax: 651-646-3124
Mailing address:
  • Phone: 763-631-1058
  • Fax: 651-646-3124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 075429-1
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number034920
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: