Healthcare Provider Details

I. General information

NPI: 1578921896
Provider Name (Legal Business Name): AUDREY LANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2016
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 FALCON DR
MOUNT STERLING KY
40353-9792
US

IV. Provider business mailing address

165 KINGSWOOD DR
TAYLORSVILLE KY
40071-6910
US

V. Phone/Fax

Practice location:
  • Phone: 859-497-5000
  • Fax:
Mailing address:
  • Phone: 502-320-2850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberR5395
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: