Healthcare Provider Details

I. General information

NPI: 1275802654
Provider Name (Legal Business Name): MS. NICHOLE J LANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 MARYLAND WAY STE 300
BRENTWOOD TN
37027-7516
US

IV. Provider business mailing address

170 PLEASANT ST.
FALL RIVER MA
02719-2505
US

V. Phone/Fax

Practice location:
  • Phone: 855-246-8607
  • Fax:
Mailing address:
  • Phone: 508-558-4305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number91658
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number63754
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: