Provider Demographics
NPI:1578332854
Name:FLACK, AMY LYNN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:FLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2605
Mailing Address - Country:US
Mailing Address - Phone:208-769-2755
Mailing Address - Fax:
Practice Address - Street 1:1120 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2605
Practice Address - Country:US
Practice Address - Phone:208-769-2755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist