MEDICARE: AMY LANE APRN, L.L.C.

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	261QM0850X	Adult Mental Health Clinic/Center	002158	CT
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center	002158	CT
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	002158	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548681786
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMY LANE APRN, L.L.C.

Provider Business Mailing Address
First Line	:	410 SALEM TPKE
Second Line	:
City	:	BOZRAH
State	:	CT
Zip	:	06334-1519
Country	:	US
Telephone Number	:	860-823-0245
Fax Number	:	860-213-8350

Provider Business Practice Location Address
First Line	:	410 SALEM TPKE
Second Line	:
City	:	BOZRAH
State	:	CT
Zip	:	06334-1519
Country	:	US
Telephone Number	:	860-823-0245
Fax Number	:	860-213-8350

Authorized Official
Title or Position	:	APRN
Name	:	AMY MICHELLE LANE
Credential	:	APRN
Telephone Number	:	860-823-0245

Provider Enumeration Date	:	12/13/2013
Last Update Date	:	04/02/2014

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