Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 421379 | NY |
NPI | 1083045074 |
---|---|
Provider Name | Octavia Lynne Flanagan |
First Address | Elmira, NY 14901-3230 |
Second Address | Elmira, NY 14905-1634 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/12/2013 |
Last Update Date | 24/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
05623143 | (05) | NY |
Q016313 | (05) | TN |