Provider Demographics
NPI:1629125927
Name:LEONE-FLYNN, MARY LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOUISE
Last Name:LEONE-FLYNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 VETERAN'S DR
Mailing Address - Street 2:ST CLOUD VA MEDICAL CENTER
Mailing Address - City:ST.CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:800-247-1739
Mailing Address - Fax:
Practice Address - Street 1:4801 VETRAN'S DR
Practice Address - Street 2:ST CLOUD VA MEDICAL CENTER
Practice Address - City:ST CLUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:800-247-1739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27908207R00000X
WI21282-020207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D65060Medicare UPIN