MEDICARE: DR. MALLORY BRYNN LANE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1205778032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MALLORY BRYNN LANE MD

Provider Business Mailing Address
First Line	:	2400 N INTERSTATE HIGHWAY 35 E
Second Line	:
City	:	WAXAHACHIE
State	:	TX
Zip	:	75165-5240
Country	:	US
Telephone Number	:	214-820-0111
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 N INTERSTATE HIGHWAY 35 E
Second Line	:
City	:	WAXAHACHIE
State	:	TX
Zip	:	75165-5240
Country	:	US
Telephone Number	:	214-820-0111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2026
Last Update Date	:	04/09/2026

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