Provider Demographics
NPI:1912045907
Name:FLANAGAN, JAIME ELLEN (MPT)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:ELLEN
Last Name:FLANAGAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BURR AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1927
Mailing Address - Country:US
Mailing Address - Phone:631-834-9533
Mailing Address - Fax:631-499-4383
Practice Address - Street 1:77 VETERANS MEMORIAL HWY
Practice Address - Street 2:SUITE 5
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3410
Practice Address - Country:US
Practice Address - Phone:631-499-4344
Practice Address - Fax:631-499-4383
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025203171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor