Healthcare Provider Details

I. General information

NPI: 1780643445
Provider Name (Legal Business Name): SHAINA MARIE LANE M.ED., ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GRAND VALLEY STATE UNIVERSITY 1 CAMPUS DR., 83 FH
ALLENDALE MI
49401
US

IV. Provider business mailing address

3707 CRYSTAL ST SW
GRANDVILLE MI
49418-1368
US

V. Phone/Fax

Practice location:
  • Phone: 616-331-3140
  • Fax:
Mailing address:
  • Phone: 616-498-4709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: