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General NPI Number Information
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NPI Number | 1508366238
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Entity Type | Individual
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Provider Name | MARY C LANE
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Gender | Female
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Dates
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Enumeration Date | 02/19/2018
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Last Update Date | 02/19/2018
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Provider Practice Location Address
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Address Line | 11049 W HOFFMAN DR
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City | ODESSA
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State | TX
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Zip | 79764-9043
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Country | US
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Telephone | 432-385-7790
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Fax |
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Provider Business Mailing Address
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Address Line | 2613 NEILL RD # 6C
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City | BIG SPRING
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State | TX
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Zip | 79720-0413
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Country | US
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Telephone | 817-401-7012
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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 | 164X00000X
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Taxonomy Name | Licensed Vocational Nurse
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License Number | 155277
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License Number State | TX
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