Basic Information
Provider Information | |||||||||
NPI: | 1336212380 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARRIS | ||||||||
FirstName: | NANCY | ||||||||
MiddleName: | LANE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 909 SE 5TH AVE | ||||||||
Address2: | SUITE 201 | ||||||||
City: | DELRAY BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334835172 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5619002498 | ||||||||
FaxNumber: | 8889724762 | ||||||||
Practice Location | |||||||||
Address1: | 55 SE 2ND AVE | ||||||||
Address2: |   | ||||||||
City: | DELRAY BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334443615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5614004118 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2006 | ||||||||
LastUpdateDate: | 04/28/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2875 | SC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LA2200X | ARNP 9162696 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 7004494 | 05 | NC |   | MEDICAID | NP0019 | 05 | SC |   | MEDICAID | P00691785 | 01 | SC | RR MEDICARE | OTHER | 196631 | 01 | SC | MEDCOST | OTHER |