Healthcare Provider Details

I. General information

NPI: 1184564379
Provider Name (Legal Business Name): LANA BUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N BONITA AVE # A
PANAMA CITY FL
32401-3623
US

IV. Provider business mailing address

2306 HIGHWAY 277
CHIPLEY FL
32428-5213
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-1511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9121877
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: