Provider Demographics
NPI:1104519339
Name:FLANAGAN, WILL (AT STUDENT)
Entity type:Individual
Prefix:
First Name:WILL
Middle Name:
Last Name:FLANAGAN
Suffix:
Gender:M
Credentials:AT STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 WEST MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:LA MOILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61330
Mailing Address - Country:US
Mailing Address - Phone:815-910-2268
Mailing Address - Fax:
Practice Address - Street 1:402 WEST MARTIN ST
Practice Address - Street 2:
Practice Address - City:LA MOILLE
Practice Address - State:IL
Practice Address - Zip Code:61330
Practice Address - Country:US
Practice Address - Phone:815-910-2268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer