Healthcare Provider Details

I. General information

NPI: 1497255293
Provider Name (Legal Business Name): FERN LANE COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 E MORRIS ST SUITE B
LA CONNER WA
98257
US

IV. Provider business mailing address

PO BOX 2104
LA CONNER WA
98257-2104
US

V. Phone/Fax

Practice location:
  • Phone: 360-630-5141
  • Fax: 866-302-7491
Mailing address:
  • Phone: 360-630-5141
  • Fax: 866-302-7491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIANNA WILSON
Title or Position: OWNER
Credential: ARNP
Phone: 360-941-5519