Healthcare Provider Details

I. General information

NPI: 1326393521
Provider Name (Legal Business Name): SHANNON FLYNN MS.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 ROUTE 17A
FLORIDA NY
10921
US

IV. Provider business mailing address

91 WEST ST
WARWICK NY
10990-1425
US

V. Phone/Fax

Practice location:
  • Phone: 845-651-2251
  • Fax:
Mailing address:
  • Phone: 845-986-5663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number278380081
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: