1255857694 NPI number — GRACE A FLYNN APN

Table of content: GRACE A FLYNN APN (NPI 1255857694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255857694 NPI number — GRACE A FLYNN APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLYNN
Provider First Name:
GRACE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255857694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1474 TANYARD ROAD
Provider Second Line Business Mailing Address:
SUITE C100
Provider Business Mailing Address City Name:
SEWELL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08080-1573
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-932-7476
Provider Business Mailing Address Fax Number:
856-566-6320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1474 TANYARD ROAD
Provider Second Line Business Practice Location Address:
SUITE C100
Provider Business Practice Location Address City Name:
SEWELL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-932-7476
Provider Business Practice Location Address Fax Number:
856-566-6320
Provider Enumeration Date:
08/17/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  26NJ00723400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: 26NJ00723400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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