Healthcare Provider Details

I. General information

NPI: 1295543510
Provider Name (Legal Business Name): MARY-CALLAHAN FLYNN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CALLIE FLYNN RD

II. Dates (important events)

Enumeration Date: 12/19/2024
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 HALSEY ST APT 3
BROOKLYN NY
11233-4280
US

IV. Provider business mailing address

838 HALSEY ST APT 3
BROOKLYN NY
11233-4280
US

V. Phone/Fax

Practice location:
  • Phone: 802-363-7800
  • Fax:
Mailing address:
  • Phone: 802-363-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number074.0134268
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: