Provider Demographics
NPI:1730519653
Name:IMM, LANA
Entity type:Individual
Prefix:
First Name:LANA
Middle Name:
Last Name:IMM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LANA
Other - Middle Name:
Other - Last Name:BLALOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8841 M 50
Mailing Address - Street 2:
Mailing Address - City:ONSTED
Mailing Address - State:MI
Mailing Address - Zip Code:49265-9552
Mailing Address - Country:US
Mailing Address - Phone:517-467-5337
Mailing Address - Fax:
Practice Address - Street 1:8841 M 50
Practice Address - Street 2:
Practice Address - City:ONSTED
Practice Address - State:MI
Practice Address - Zip Code:49265-9552
Practice Address - Country:US
Practice Address - Phone:517-467-5337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 376J00000X, 374U00000X, 171M00000X, 174H00000X
MI372600000X, 374U00000X, 372500000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No376J00000XNursing Service Related ProvidersHomemaker
No372600000XNursing Service Related ProvidersAdult Companion
No372500000XNursing Service Related ProvidersChore Provider
No376K00000XNursing Service Related ProvidersNurse's Aide
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174H00000XOther Service ProvidersHealth Educator