Healthcare Provider Details

I. General information

NPI: 1487767091
Provider Name (Legal Business Name): MARY ANNE LANE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 SEMINARY ST.
KENANSVILLE NC
28349
US

IV. Provider business mailing address

350 LUDIE BROWN RD
CHINQUAPIN NC
28521-8638
US

V. Phone/Fax

Practice location:
  • Phone: 910-296-2130
  • Fax: 910-296-2139
Mailing address:
  • Phone: 910-285-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number063889
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: