Healthcare Provider Details

I. General information

NPI: 1609856442
Provider Name (Legal Business Name): PENNY COMBS LANE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR NAVAL MEDICAL CENTER
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

1080 FIRST COLONIAL RD STE 412
VIRGINIA BEACH VA
23454-2406
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-5966
  • Fax:
Mailing address:
  • Phone: 757-395-6500
  • Fax: 757-275-9885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101047421
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: