Provider Demographics
NPI:1043420896
Name:LANE, JUDY (NP, RN)
Entity Type:Individual
Prefix:MS
First Name:JUDY
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:NP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MARIN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6806
Mailing Address - Country:US
Mailing Address - Phone:415-883-3955
Mailing Address - Fax:415-472-7636
Practice Address - Street 1:25 MITCHELL BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2007
Practice Address - Country:US
Practice Address - Phone:415-472-2343
Practice Address - Fax:415-472-7636
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA501901363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health