Provider Demographics
NPI:1932613833
Name:NINO LAGOS, OLGA PATRICIA
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:PATRICIA
Last Name:NINO LAGOS
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 1:6406 BLUEBONNET DR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-1682
Mailing Address - Country:US
Mailing Address - Phone:469-363-3221
Mailing Address - Fax:
Practice Address - Street 1:930 W CENTERVILLE RD STE 370
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041-5823
Practice Address - Country:US
Practice Address - Phone:469-364-8680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214890224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty