Provider Demographics
NPI:1629267091
Name:FLANAGAN, WENDY M (LMT)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:M
Last Name:FLANAGAN
Suffix:
Gender:F
Credentials:LMT
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 25
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:FL
Mailing Address - Zip Code:32640-0025
Mailing Address - Country:US
Mailing Address - Phone:352-336-0872
Mailing Address - Fax:352-481-3735
Practice Address - Street 1:900 NW 8TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-5059
Practice Address - Country:US
Practice Address - Phone:352-336-0872
Practice Address - Fax:352-481-3735
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA34335173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC8108OtherBLUECROSSBLUESHIELD