Provider Demographics
NPI:1326393521
Name:FLYNN, SHANNON (MSED)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FLYNN
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1425
Mailing Address - Country:US
Mailing Address - Phone:845-986-5663
Mailing Address - Fax:
Practice Address - Street 1:1751 ROUTE 17A
Practice Address - Street 2:
Practice Address - City:FLORIDA
Practice Address - State:NY
Practice Address - Zip Code:10921
Practice Address - Country:US
Practice Address - Phone:845-651-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278380081174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist