Healthcare Provider Details

I. General information

NPI: 1215920301
Provider Name (Legal Business Name): JENNIFER MARY LANE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 MONTVALE AVE STE 208
STONEHAM MA
02180-3649
US

IV. Provider business mailing address

91 MONTVALE AVE STE 208
STONEHAM MA
02180-3649
US

V. Phone/Fax

Practice location:
  • Phone: 781-306-6166
  • Fax: 781-418-1919
Mailing address:
  • Phone: 781-306-6166
  • Fax: 781-418-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number247127
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: