Healthcare Provider Details

I. General information

NPI: 1679408611
Provider Name (Legal Business Name): LANE EVAN EDMONDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 RAILROAD ST
ELIZABETHTON TN
37643-2504
US

IV. Provider business mailing address

865 WOODMONT RD
JONESBOROUGH TN
37659-3766
US

V. Phone/Fax

Practice location:
  • Phone: 423-297-1813
  • Fax:
Mailing address:
  • Phone: 423-491-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9138
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: