Provider Demographics
NPI:1053170415
Name:FLYNN, AMBER CARISSA
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:CARISSA
Last Name:FLYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2833 LYNDALE AVE S APT 503
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4399
Mailing Address - Country:US
Mailing Address - Phone:503-453-0043
Mailing Address - Fax:
Practice Address - Street 1:2700 GA-34
Practice Address - Street 2:BLDG 300
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:678-423-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPENDING152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist