Provider Demographics
NPI:1558411892
Name:FLYNN, THERESA (ANP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:FLYNN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 RICHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5743
Mailing Address - Country:US
Mailing Address - Phone:617-724-0072
Mailing Address - Fax:617-643-2899
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:COX 626
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-724-0072
Practice Address - Fax:617-643-2899
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA117640163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse