Healthcare Provider Details

I. General information

NPI: 1386163590
Provider Name (Legal Business Name): TIMEKA LANE MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIMEKA MONTGOMERY

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12598 ESTATE AVE NW
UNIONTOWN OH
44685-5780
US

IV. Provider business mailing address

12598 ESTATE AVE NW
UNIONTOWN OH
44685-5780
US

V. Phone/Fax

Practice location:
  • Phone: 330-990-4413
  • Fax:
Mailing address:
  • Phone: 330-990-4413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number319644
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number319644
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number319644
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: