Provider Demographics
NPI:1760855514
Name:FYNN, EGLA
Entity Type:Individual
Prefix:
First Name:EGLA
Middle Name:
Last Name:FYNN
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 1:7767 RIVERDALE RD
Mailing Address - Street 2:APT 303
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3929
Mailing Address - Country:US
Mailing Address - Phone:732-763-0938
Mailing Address - Fax:
Practice Address - Street 1:2046 WALDEN CT
Practice Address - Street 2:
Practice Address - City:BRYANS ROAD
Practice Address - State:MD
Practice Address - Zip Code:20616-6016
Practice Address - Country:US
Practice Address - Phone:732-763-0938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide