Provider Demographics
NPI:1497840003
Name:FLYNN, VICKI LORRAINE (CRNA)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LORRAINE
Last Name:FLYNN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:LORRAINE
Other - Last Name:ADEMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:15490 293RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398
Mailing Address - Country:US
Mailing Address - Phone:763-631-1058
Mailing Address - Fax:651-646-3124
Practice Address - Street 1:1544 SHELDON STREET
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108
Practice Address - Country:US
Practice Address - Phone:651-646-3091
Practice Address - Fax:651-646-3124
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 075429-1163W00000X
MN034920367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse