Healthcare Provider Details

I. General information

NPI: 1184178758
Provider Name (Legal Business Name): MELANIE LANE-DAVIS QBHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELANIE RUTH LANE

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 E CRANDALL AVE # B
HARRISON AR
72601-3628
US

IV. Provider business mailing address

4171 N CROSSOVER RD
FAYETTEVILLE AR
72703-4591
US

V. Phone/Fax

Practice location:
  • Phone: 870-741-8484
  • Fax:
Mailing address:
  • Phone: 479-521-1427
  • Fax: 479-521-6520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: