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General NPI Number Information
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NPI Number | 1396787321
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Entity Type | Individual
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Provider Name | KELLIE V LANE M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/12/2006
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Last Update Date | 11/06/2013
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Provider Practice Location Address
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Address Line | 818 SAINT SEBASTIAN WAY SUITE 311
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City | AUGUSTA
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State | GA
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Zip | 30901-2651
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Country | US
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Telephone | 706-724-3473
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Fax |
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Provider Business Mailing Address
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Address Line | 4354 DEERWOOD LN
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City | EVANS
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State | GA
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Zip | 30809-4604
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Country | US
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Telephone | 706-210-1449
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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 | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 043233
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License Number State | GA
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