Healthcare Provider Details

I. General information

NPI: 1669548301
Provider Name (Legal Business Name): LAURENCE B LANE CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 SUNRISE CT
FESTUS MO
63028
US

IV. Provider business mailing address

132 SUNRISE CT
FESTUS MO
63028
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-2147
  • Fax: 636-933-3908
Mailing address:
  • Phone: 636-933-2147
  • Fax: 636-933-3908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number069722
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: