Provider Demographics
NPI:1124398474
Name:FLANIGAN, JOHANNA M (RN)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:M
Last Name:FLANIGAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 GETTLE ROAD, ST. 1
Mailing Address - Street 2:
Mailing Address - City:AVERILL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12018
Mailing Address - Country:US
Mailing Address - Phone:518-674-7050
Mailing Address - Fax:518-674-3802
Practice Address - Street 1:146 GETTLE ROAD
Practice Address - Street 2:
Practice Address - City:AVERILL PARK
Practice Address - State:NY
Practice Address - Zip Code:12018
Practice Address - Country:US
Practice Address - Phone:518-674-7020
Practice Address - Fax:518-674-7052
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217157163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01379024Medicaid