Healthcare Provider Details

I. General information

NPI: 1861557902
Provider Name (Legal Business Name): LAURIE ANN FLAGG INACIO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 MDTS/SGVDD 2200 BERGQUIST DRIVE, STE 1
LACKLAND AIR FORCE BASE TX
78236
US

IV. Provider business mailing address

9931 HYATT RESORT DR APT 1721
SAN ANTONIO TX
78251-4181
US

V. Phone/Fax

Practice location:
  • Phone: 210-292-6512
  • Fax:
Mailing address:
  • Phone: 702-513-3060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberADA 861579
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: