Provider Demographics
NPI:1083045074
Name:FLANAGAN, OCTAVIA LYNNE (RN, PHD)
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:LYNNE
Last Name:FLANAGAN
Suffix:
Gender:F
Credentials:RN, PHD
Other - Prefix:MISS
Other - First Name:OCTAVIA
Other - Middle Name:LYNNE
Other - Last Name:BLACKWELDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:600 FITCH ST STE 102
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1634
Practice Address - Country:US
Practice Address - Phone:607-734-6544
Practice Address - Fax:607-734-6580
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY421379363LW0102X
NC940006363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ016313Medicaid
NY05623143Medicaid