Basic Information
| Provider Information | |||||||||
| NPI: | 1215376751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | BOURGEOIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANE | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1321 HUNTSVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373343603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312972201 | ||||||||
| FaxNumber: | 9312972206 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 BOB WALLACE AVE SW STE E | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358013843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565395339 | ||||||||
| FaxNumber: | 2565365111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 03/28/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN0000019106 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 1-035725 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.