Healthcare Provider Details

I. General information

NPI: 1952765745
Provider Name (Legal Business Name): KELLY LANE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 NORTHWEST BLVD
NASHUA NH
03063-4068
US

IV. Provider business mailing address

PO BOX 3677
NASHUA NH
03061-3677
US

V. Phone/Fax

Practice location:
  • Phone: 603-577-2273
  • Fax: 603-579-5191
Mailing address:
  • Phone: 603-577-7900
  • Fax: 603-577-7972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1164
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: