Healthcare Provider Details

I. General information

NPI: 1154317717
Provider Name (Legal Business Name): CAROLYN GRANT LANE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROLYN E LANE

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S STATE ST
DOVER DE
19901-3530
US

IV. Provider business mailing address

PO BOX 10925
WILMINGTON DE
19850-0925
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-4700
  • Fax:
Mailing address:
  • Phone: 302-709-4587
  • Fax: 302-709-2402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL1-0014393
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberL6-0A00205
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: