Basic Information
| Provider Information | |||||||||
| NPI: | 1891421103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANE | ||||||||
| FirstName: | CIERRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | BS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4722 RIVERSTONE BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MISSOURI CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774594723 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4722 RIVERSTONE BLVD | ||||||||
| Address2: | UNIT 100 | ||||||||
| City: | MISSOURI CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3463684412 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2022 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.