Healthcare Provider Details

I. General information

NPI: 1427571017
Provider Name (Legal Business Name): STEPHANIE J LANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE JEAN GROGG

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 11/27/2023
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 SIGNAL HILL DRIVE EXT
STATESVILLE NC
28625-4391
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR STE 100
CONCORD NC
28025-1833
US

V. Phone/Fax

Practice location:
  • Phone: 704-871-1045
  • Fax: 704-873-6647
Mailing address:
  • Phone: 704-939-1100
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5009765
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5009765
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5009765
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: