Healthcare Provider Details

I. General information

NPI: 1093765232
Provider Name (Legal Business Name): KIMBERLY J LANE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 POMFRET ST
PUTNAM CT
06260-1836
US

IV. Provider business mailing address

320 POMFRET ST
PUTNAM CT
06260-1836
US

V. Phone/Fax

Practice location:
  • Phone: 860-928-6541
  • Fax: 860-963-6393
Mailing address:
  • Phone: 860-928-6541
  • Fax: 860-963-6393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number000708
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: