Healthcare Provider Details

I. General information

NPI: 1356650360
Provider Name (Legal Business Name): TABITHA MARIE LANE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2010
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 SW HEALTH PKWY STE 205
NAPLES FL
34109-0473
US

IV. Provider business mailing address

1890 SW HEALTH PKWY STE 205
NAPLES FL
34109-0473
US

V. Phone/Fax

Practice location:
  • Phone: 239-449-7979
  • Fax: 239-593-3356
Mailing address:
  • Phone: 239-449-7979
  • Fax: 239-593-3356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3062
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9120043
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: