MEDICARE: MS. WAQUITA NICOLE LANE MPT

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	225100000X	Physical Therapist	9952	NC

General Provider Information

NPI Number	:	1285640359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. WAQUITA NICOLE LANE MPT

Provider Business Mailing Address
First Line	:	PO BOX 92
Second Line	:
City	:	HALIFAX
State	:	NC
Zip	:	27839-0092
Country	:	US
Telephone Number	:	252-583-3681
Fax Number	:

Provider Business Practice Location Address
First Line	:	2413 PROFESSIONAL DR
Second Line	:
City	:	ROANOKE RAPIDS
State	:	NC
Zip	:	27870-3221
Country	:	US
Telephone Number	:	252-535-3028
Fax Number	:	252-535-4775

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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