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General NPI Number Information
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NPI Number | 1316477326
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Entity Type | Individual
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Provider Name | SHANNON R LANE FNP-C
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Gender | Female
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Dates
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Enumeration Date | 06/13/2017
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Last Update Date | 06/13/2017
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Provider Practice Location Address
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Address Line | 1960 FREEDOM PKWY
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City | WASHINGTON
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State | IL
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Zip | 61571-9468
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Country | US
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Telephone | 309-745-7425
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Fax |
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Provider Business Mailing Address
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Address Line | 113 W FRANKLIN ST
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City | MC LEAN
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State | IL
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Zip | 61754-9624
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Country | US
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Telephone | 309-287-5555
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209.016035
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License Number State | IL
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