Provider Demographics
NPI:1003699240
Name:LANE, BARBARA MALLORY (NP)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:MALLORY
Last Name:LANE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4233 CAMELOT CROSSING
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-6926
Mailing Address - Country:US
Mailing Address - Phone:229-469-4383
Mailing Address - Fax:
Practice Address - Street 1:4233 CAMELOT CROSSING
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6926
Practice Address - Country:US
Practice Address - Phone:229-469-4383
Practice Address - Fax:229-469-4584
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN203145207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology