Provider Demographics
NPI:1770995649
Name:BOGAN, CAROLYN JANE (FNP-BC)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JANE
Last Name:BOGAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:JANE
Other - Last Name:HABLITZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:409 MITCHELL RD
Mailing Address - Street 2:
Mailing Address - City:LORENA
Mailing Address - State:TX
Mailing Address - Zip Code:76655-9418
Mailing Address - Country:US
Mailing Address - Phone:254-744-8206
Mailing Address - Fax:254-857-4462
Practice Address - Street 1:6363 N STATE HIGHWAY 161 STE 100
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2239
Practice Address - Country:US
Practice Address - Phone:469-200-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661649163WP2201X
TXAP125985363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care