=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922635440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHELSEA ANN LANE DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2020
-----------------------------------------------------
Last Update Date | 03/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 KENNEDY MEMORIAL DR
-----------------------------------------------------
City | WATERVILLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04901-4526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-873-5123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 FAIRVIEW AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-3005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-938-6838
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT5566
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------