Healthcare Provider Details

I. General information

NPI: 1245626712
Provider Name (Legal Business Name): KYRSTIN LYNNICE LANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2015
Last Update Date: 03/07/2023
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W 7TH ST STE S-270D
LOS ANGELES CA
90017-3768
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 213-988-8380
  • Fax: 213-988-8390
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA155305
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: