Healthcare Provider Details

I. General information

NPI: 1902509755
Provider Name (Legal Business Name): LEE A LANE DPM, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 W PARKVIEW ST STE 2J
BOLIVAR MO
65613-8598
US

IV. Provider business mailing address

1155 W PARKVIEW ST STE 2J
BOLIVAR MO
65613-8598
US

V. Phone/Fax

Practice location:
  • Phone: 417-328-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2026030577
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: