MEDICARE: SHANNON R LANE FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209.016035	IL

General Provider Information

NPI Number	:	1316477326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON R LANE FNP-C

Provider Business Mailing Address
First Line	:	113 W FRANKLIN ST
Second Line	:
City	:	MC LEAN
State	:	IL
Zip	:	61754-9624
Country	:	US
Telephone Number	:	309-287-5555
Fax Number	:

Provider Business Practice Location Address
First Line	:	1960 FREEDOM PKWY
Second Line	:
City	:	WASHINGTON
State	:	IL
Zip	:	61571-9468
Country	:	US
Telephone Number	:	309-745-7425
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2017
Last Update Date	:	06/13/2017

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