Provider Demographics
NPI:1689142812
Name:VANVECHTEN-FLYNN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VANVECHTEN-FLYNN
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 1:33 CAROLINE AVE
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3008
Mailing Address - Country:US
Mailing Address - Phone:516-383-4369
Mailing Address - Fax:
Practice Address - Street 1:30 ROUTE 111
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3713
Practice Address - Country:US
Practice Address - Phone:631-724-2299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014604-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist