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General NPI Number Information
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NPI Number | 1063039311
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Entity Type | Individual
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Provider Name | GAVIN LEE FLENTGE AGACNP-BC
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Gender | Male
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Dates
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Enumeration Date | 07/02/2020
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Last Update Date | 08/10/2021
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Provider Practice Location Address
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Address Line | 8 N FRENCH LN
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City | PERRYVILLE
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State | MO
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Zip | 63775-1577
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Country | US
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Telephone | 573-768-6986
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Fax | 949-655-8621
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Provider Business Mailing Address
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Address Line | 8 N FRENCH LN
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City | PERRYVILLE
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State | MO
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Zip | 63775-1577
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Country | US
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Telephone | 573-768-6986
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Fax | 949-655-8621
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 2020019956
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License Number State | MO
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