Provider Demographics
NPI:1073099503
Name:LANE, TRACY ELAINE (AGPCNP-CNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ELAINE
Last Name:LANE
Suffix:
Gender:F
Credentials:AGPCNP-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20169 E 960 RD
Mailing Address - Street 2:
Mailing Address - City:HAMMON
Mailing Address - State:OK
Mailing Address - Zip Code:73650-5032
Mailing Address - Country:US
Mailing Address - Phone:580-309-0461
Mailing Address - Fax:
Practice Address - Street 1:20169 E 960 RD
Practice Address - Street 2:
Practice Address - City:HAMMON
Practice Address - State:OK
Practice Address - Zip Code:73650-5032
Practice Address - Country:US
Practice Address - Phone:580-309-0461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK71743363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health