Basic Information
| Provider Information | |||||||||
| NPI: | 1407971153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANE-BRINK | ||||||||
| FirstName: | ROXANNE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RNC, WHCNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3815 S. VAL VISTA DRIVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807820993 | ||||||||
| FaxNumber: | 8553298939 | ||||||||
| Practice Location | |||||||||
| Address1: | 3815 S. VAL VISTA DRIVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807820993 | ||||||||
| FaxNumber: | 8553298939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 11/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | AP0343 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | ML0717679 | 01 | AZ | DEA | OTHER | 356946 | 05 | AZ | MEDICAID |