Provider Demographics
NPI:1902052889
Name:FLYNN, MARY JO DORIS (RN)
Entity type:Individual
Prefix:
First Name:MARY JO
Middle Name:DORIS
Last Name:FLYNN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 THURBER DR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1600
Mailing Address - Country:US
Mailing Address - Phone:315-539-1930
Mailing Address - Fax:
Practice Address - Street 1:31 THURBER DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1600
Practice Address - Country:US
Practice Address - Phone:315-539-1930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY407751-0163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse