Provider Demographics
NPI:1629142716
Name:FLYNN, SHANNON ELIZABETH (OTR-L)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:FLYNN
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 ARRINGDON PARK DR
Mailing Address - Street 2:APT 204
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-7446
Mailing Address - Country:US
Mailing Address - Phone:518-542-1027
Mailing Address - Fax:
Practice Address - Street 1:1611 JONES FRANKLIN RD
Practice Address - Street 2:SUITE 109
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-3376
Practice Address - Country:US
Practice Address - Phone:919-852-0702
Practice Address - Fax:919-852-0742
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4928225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301605Medicaid