Provider Demographics
NPI:1952689747
Name:FLYNN, NICOLE E (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:FLYNN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:E
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 708760
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-8760
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-7976
Practice Address - Street 1:1 CLARA MAASS DR
Practice Address - Street 2:KIDDLE HALL SUITE 204
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3550
Practice Address - Country:US
Practice Address - Phone:973-450-2432
Practice Address - Fax:973-450-2434
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00240100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant