Provider Demographics
NPI:1891432266
Name:BLAGG, LANA J
Entity Type:Individual
Prefix:
First Name:LANA
Middle Name:J
Last Name:BLAGG
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 458
Mailing Address - Street 2:
Mailing Address - City:POTEET
Mailing Address - State:TX
Mailing Address - Zip Code:78065-0458
Mailing Address - Country:US
Mailing Address - Phone:210-334-9230
Mailing Address - Fax:
Practice Address - Street 1:344 OAK CREEK ESTATES RD
Practice Address - Street 2:
Practice Address - City:POTEET
Practice Address - State:TX
Practice Address - Zip Code:78065-4019
Practice Address - Country:US
Practice Address - Phone:210-334-9230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1069252363LG0600X, 363LP0808X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care