Healthcare Provider Details

I. General information

NPI: 1255857694
Provider Name (Legal Business Name): GRACE A FLYNN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1474 TANYARD ROAD SUITE C100
SEWELL NJ
08080
US

IV. Provider business mailing address

1474 TANYARD ROAD SUITE C100
SEWELL NJ
08080-1573
US

V. Phone/Fax

Practice location:
  • Phone: 856-932-7476
  • Fax: 856-566-6320
Mailing address:
  • Phone: 856-932-7476
  • Fax: 856-566-6320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00723400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ00723400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: