Healthcare Provider Details

I. General information

NPI: 1780052746
Provider Name (Legal Business Name): ALISA NICOLE LANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALISA NICOLE WILDANGER

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HOWE AVE STE 400-B
SACRAMENTO CA
95825-4731
US

IV. Provider business mailing address

650 HOWE AVE STE 400-B
SACRAMENTO CA
95825-4731
US

V. Phone/Fax

Practice location:
  • Phone: 916-993-4131
  • Fax:
Mailing address:
  • Phone: 916-993-4131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: