Basic Information
| Provider Information | |||||||||
| NPI: | 1811936289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'FLYNN | ||||||||
| FirstName: | LEISA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22581 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100872581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104824795 | ||||||||
| FaxNumber: | 8565283117 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 COLSON LN | ||||||||
| Address2: | |||||||||
| City: | MULLICA HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080621502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562238930 | ||||||||
| FaxNumber: | 8562238948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 25MB07830600 | NJ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0081680 | 05 | NJ | MEDICAID |