Healthcare Provider Details

I. General information

NPI: 1790948727
Provider Name (Legal Business Name): AUTUMN LEA LANE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHILDRENS DRIVE
COLUMBUS OH
43205
US

IV. Provider business mailing address

700 CHILDRENS DRIVE J4 NICU NNP PROGRAM
COLUMBUS OH
43205
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-6510
  • Fax: 722-722-4772
Mailing address:
  • Phone: 614-722-6510
  • Fax: 722-722-4772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberAPRN.CNP.08976
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberAPRN.CNP.08976
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: