Healthcare Provider Details

I. General information

NPI: 1053896522
Provider Name (Legal Business Name): JENNIFER LAINE MSN, RN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA LAINE

II. Dates (important events)

Enumeration Date: 10/01/2018
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W BEN WHITE BLVD
AUSTIN TX
78704
US

IV. Provider business mailing address

208 W BEN WHITE BLVD
AUSTIN TX
78704-7126
US

V. Phone/Fax

Practice location:
  • Phone: 512-861-8060
  • Fax:
Mailing address:
  • Phone: 512-861-8060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP138746
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: