=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245540459
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALLORY JEAN FLYNN RPA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2010
-----------------------------------------------------
Last Update Date | 01/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3288 MOANALUA RD
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96819-1469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-432-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 159 MOOKUA ST
-----------------------------------------------------
City | KAILUA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96734-5842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-524-1052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 014409
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------