Healthcare Provider Details

I. General information

NPI: 1417530213
Provider Name (Legal Business Name): AMANDA LYNETTE FLYNN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 CHAMBERS DR
O FALLON MO
63366-3476
US

IV. Provider business mailing address

1415 CHAMBERS DR
O FALLON MO
63366-3476
US

V. Phone/Fax

Practice location:
  • Phone: 636-578-0890
  • Fax:
Mailing address:
  • Phone: 636-578-0890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018006304
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: