Provider Demographics
NPI:1649240938
Name:LAGO, HOLLY J (C-FNP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:J
Last Name:LAGO
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:J
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:C-FNP
Mailing Address - Street 1:PO BOX 746093
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6093
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:1940 W INDIAN SCHOOL RD STE 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-5112
Practice Address - Country:US
Practice Address - Phone:602-782-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR134082-4363L00000X
MO2020040251363LF0000X
KS80303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN886467500Medicaid
13620OtherAVERA
253254OtherMIDLANDS CHOICE
MN281G0KOOtherBLUE CROSS BLUE SHIELD
974311045631OtherPREF ONE
806278OtherAMERICAS PPO
0121785OtherMEDICA
135445OtherUCARE
MN435M6KOOtherBLUE CROSS BLUE SHIELD
IA0599456Medicaid
47358OtherSANFORD HEALTH
HP56828OtherHEALTHPARTNERS
P00365643OtherRAILROAD MEDICARE
0121785OtherMEDICA
MN500003120Medicare PIN