Healthcare Provider Details

I. General information

NPI: 1720642390
Provider Name (Legal Business Name): LANE WYBLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 BROADMOOR BLVD STE B
MONROE LA
71201-2994
US

IV. Provider business mailing address

130 DESIARD ST STE 355
MONROE LA
71201-7363
US

V. Phone/Fax

Practice location:
  • Phone: 318-807-0525
  • Fax: 318-807-1077
Mailing address:
  • Phone: 318-807-7875
  • Fax: 318-812-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN136523
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number206936
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: