Healthcare Provider Details

I. General information

NPI: 1144549379
Provider Name (Legal Business Name): SAMANTHA COLLEEN LANE IDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W MARINE VIEW DR # 2134
EVERETT WA
98207-2900
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 425-304-4343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: