Provider Demographics
NPI:1093305401
Name:MOGENSEN, LYNN IDELL (FNP)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:IDELL
Last Name:MOGENSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:IDELL
Other - Last Name:LATOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2004 NOTTINGHAM BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-5229
Mailing Address - Country:US
Mailing Address - Phone:530-949-1291
Mailing Address - Fax:
Practice Address - Street 1:2004 NOTTINGHAM BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-5229
Practice Address - Country:US
Practice Address - Phone:530-949-1291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1025471363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily