Healthcare Provider Details

I. General information

NPI: 1578532032
Provider Name (Legal Business Name): MARY E LANE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N WILLSON SUITE 2001
BOZEMAN MT
59715-3572
US

IV. Provider business mailing address

300 N WILLSON SUITE 2001
BOZEMAN MT
59715-3572
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-0681
  • Fax: 406-587-9011
Mailing address:
  • Phone: 406-587-0681
  • Fax: 406-587-9011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN18707
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: