Provider Demographics
NPI:1295021194
Name:GANAGO, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:GANAGO
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:PO BOX 86537
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:520-344-8892
Practice Address - Street 1:6625 S LANTANA VISTA DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85756-8675
Practice Address - Country:US
Practice Address - Phone:520-721-1887
Practice Address - Fax:520-344-8892
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP046337164W00000X
AZBH5661171W00000X
AZRN189398163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ635634Medicaid
AZBH5661OtherBRFL LICENSE (BEHAVIORAL HEALTH THERAPEUTIC HOME)