Provider Demographics
NPI:1760618292
Name:FLYNN, MATTHEW EDWARD (FNP, ACNP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EDWARD
Last Name:FLYNN
Suffix:
Gender:M
Credentials:FNP, ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DR STE 1052
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4609
Mailing Address - Country:US
Mailing Address - Phone:601-981-9503
Mailing Address - Fax:601-982-1198
Practice Address - Street 1:971 LAKELAND DR STE 1052
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4609
Practice Address - Country:US
Practice Address - Phone:601-981-9503
Practice Address - Fax:601-982-1198
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860587363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05156038Medicaid
MS7885550OtherCIGNA
MSP00775214OtherRAILROAD MEDICARE
MS05156038Medicaid