=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154982783
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA JEAN LANE MSN, RN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2019
-----------------------------------------------------
Last Update Date | 08/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 MAIN ST
-----------------------------------------------------
City | DOWAGIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49047-1762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-783-3052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1014 WESTMORELAND AVE
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49006-5544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-494-0833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704343669
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------