Basic Information
| Provider Information | |||||||||
| NPI: | 1821414723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | LANAE | ||||||||
| MiddleName: | WYNNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 S PATTERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454022684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374962620 | ||||||||
| FaxNumber: | 9374962620 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 S PATTERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454022684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374962620 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2014 | ||||||||
| LastUpdateDate: | 03/16/2014 | ||||||||
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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 | 246ZS0410X | 113810 | OH | Y |
No ID Information.