Healthcare Provider Details

I. General information

NPI: 1003008863
Provider Name (Legal Business Name): HOLLY SUE FLYNN LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1963 BETHEL RD SE
PORT ORCHARD WA
98366-3108
US

IV. Provider business mailing address

PO BOX 1222
PORT ORCHARD WA
98366
US

V. Phone/Fax

Practice location:
  • Phone: 360-710-7747
  • Fax: 360-895-0447
Mailing address:
  • Phone: 360-710-7747
  • Fax: 360-895-0447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberMA00014461
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: