Basic Information
| Provider Information | |||||||||
| NPI: | 1932496973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLYNN | ||||||||
| FirstName: | ANTONIA | ||||||||
| MiddleName: | CAROLINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAGGARTY | ||||||||
| OtherFirstName: | ANTONIA | ||||||||
| OtherMiddleName: | CAROLINE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5677 OBERLIN DR | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584578419 | ||||||||
| FaxNumber: | 8584570670 | ||||||||
| Practice Location | |||||||||
| Address1: | 5677 OBERLIN DR | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584578419 | ||||||||
| FaxNumber: | 8584570670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2011 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 37898 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.