Healthcare Provider Details

I. General information

NPI: 1760618292
Provider Name (Legal Business Name): MATTHEW EDWARD FLYNN FNP, ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 1052
JACKSON MS
39216-4609
US

IV. Provider business mailing address

971 LAKELAND DR STE 1052
JACKSON MS
39216-4609
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-9503
  • Fax: 601-982-1198
Mailing address:
  • Phone: 601-981-9503
  • Fax: 601-982-1198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR860587
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR860587
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: