1508293374 NPI number — KERI LYN DRAGANIC NP

Table of content: KERI LYN DRAGANIC NP (NPI 1508293374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508293374 NPI number — KERI LYN DRAGANIC NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRAGANIC
Provider First Name:
KERI
Provider Middle Name:
LYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'DONNELL
Provider Other First Name:
KERI
Provider Other Middle Name:
LYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508293374
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 845347
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75284-5347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-291-2841
Provider Business Mailing Address Fax Number:
214-645-0078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5323 HARRY HINES BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75390-7201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-633-5555
Provider Business Practice Location Address Fax Number:
214-648-9104
Provider Enumeration Date:
10/10/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  AP124571 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)