Healthcare Provider Details

I. General information

NPI: 1457932337
Provider Name (Legal Business Name): MICHAEL JENNINGS LANE SR. DNP PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10110 DONALD S POWERS DR STE 101C
MUNSTER IN
46321-4070
US

IV. Provider business mailing address

10110 DONALD S POWERS DR STE 101C
MUNSTER IN
46321-4070
US

V. Phone/Fax

Practice location:
  • Phone: 269-250-8013
  • Fax: 877-326-2856
Mailing address:
  • Phone: 269-250-8013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number041354134
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number28230854A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209023083
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71011081A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: