Provider Demographics
NPI:1265462683
Name:FLYNN, BEVERLY SUE (LDO)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:SUE
Last Name:FLYNN
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PALERMO PL
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-2820
Mailing Address - Country:US
Mailing Address - Phone:941-485-7316
Mailing Address - Fax:941-486-0571
Practice Address - Street 1:200 PALERMO PL
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2820
Practice Address - Country:US
Practice Address - Phone:941-485-7316
Practice Address - Fax:941-486-0571
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1449156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0595790001Medicare NSC