Provider Demographics
NPI:1609245349
Name:FLICKINGER, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FLICKINGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 1ST ST E
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-1524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19021 FREEPORT ST NW
Practice Address - Street 2:STE 400
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1278
Practice Address - Country:US
Practice Address - Phone:763-633-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 219231-4163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health