Healthcare Provider Details

I. General information

NPI: 1295644649
Provider Name (Legal Business Name): ILLEANA LANESE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 DAVIS AVE
LANSING MI
48910-9004
US

IV. Provider business mailing address

1808 DAVIS AVE
LANSING MI
48910-9004
US

V. Phone/Fax

Practice location:
  • Phone: 517-974-9834
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601013977
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: