Provider Demographics
NPI:1760434476
Name:FLAVIN, PENNY LOUISE
Entity Type:Individual
Prefix:
First Name:PENNY LOUISE
Middle Name:
Last Name:FLAVIN
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 1:111 COUNTY ROAD 11 NW
Mailing Address - Street 2:
Mailing Address - City:PINE ISLAND
Mailing Address - State:MN
Mailing Address - Zip Code:55963-9756
Mailing Address - Country:US
Mailing Address - Phone:507-356-4929
Mailing Address - Fax:
Practice Address - Street 1:111 COUNTY ROAD 11 NW
Practice Address - Street 2:
Practice Address - City:PINE ISLAND
Practice Address - State:MN
Practice Address - Zip Code:55963-9756
Practice Address - Country:US
Practice Address - Phone:507-356-4929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0980311363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN632240900Medicaid
500002158OtherMEDICARE CLINIC
500002158OtherMEDICARE LEGACY
1760434476OtherNPI
500002159OtherMEDICARE HOSPITAL