Provider Demographics
NPI:1740697846
Name:FLANNIGAN, LAVONDA
Entity type:Individual
Prefix:
First Name:LAVONDA
Middle Name:
Last Name:FLANNIGAN
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 1:9825 MAGNOLIA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-7375
Practice Address - Fax:817-702-2787
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2500834163W00000X
CA281266164X00000X
TX988991163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11241000383Medicaid