Healthcare Provider Details

I. General information

NPI: 1083799548
Provider Name (Legal Business Name): JENNIFER LANE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 EASTWAY DR
CHARLOTTE NC
28213-7103
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-446-9991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number9600601
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: