Healthcare Provider Details

I. General information

NPI: 1194210898
Provider Name (Legal Business Name): LANONA D REZAC CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7166 COUNTY ROAD 154
SALIDA CO
81201-9455
US

IV. Provider business mailing address

PO BOX 840
SEMINOLE TX
79360
US

V. Phone/Fax

Practice location:
  • Phone: 719-276-5488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberC-APN.0104759-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: