MEDICARE: LANE E WILSON MS, RD

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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1750054045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANE E WILSON MS, RD

Provider Business Mailing Address
First Line	:	1721 NE 34TH LN
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-7356
Country	:	US
Telephone Number	:	217-714-0203
Fax Number	:

Provider Business Practice Location Address
First Line	:	1721 NE 34TH LN
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-7356
Country	:	US
Telephone Number	:	217-714-0203
Fax Number	:

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

Provider Enumeration Date	:	08/01/2021
Last Update Date	:	08/01/2021

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