Healthcare Provider Details

I. General information

NPI: 1912569385
Provider Name (Legal Business Name): ALEXIS NICOLE LANE PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 LAKE AVE
FORT WAYNE IN
46805-5100
US

IV. Provider business mailing address

8648 TOZER CT APT 4
PORTAGE MI
49024-4809
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-5431
  • Fax:
Mailing address:
  • Phone: 260-446-6573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26028218A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: