Provider Demographics
NPI:1588412704
Name:FLYNN, KIMBERLY ANN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:FLYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:FARRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:47 NEWBURY ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-3939
Mailing Address - Country:US
Mailing Address - Phone:978-360-8914
Mailing Address - Fax:
Practice Address - Street 1:2 COURTHOUSE LN STE 10
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-1723
Practice Address - Country:US
Practice Address - Phone:978-360-8914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1290133V00000X
MA5318133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered