Healthcare Provider Details

I. General information

NPI: 1811418569
Provider Name (Legal Business Name): EMILY LANE MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY KORNEGAY RD LD

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 COOPER ST
FORT WORTH TX
76104-2710
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-1202
  • Fax: 682-885-1204
Mailing address:
  • Phone: 682-885-6483
  • Fax: 682-885-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT83361
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: