Provider Demographics
NPI:1083102495
Name:LANE, TRACY NICOLE (DPH)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:NICOLE
Last Name:LANE
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 LERCH ST
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-4531
Mailing Address - Country:US
Mailing Address - Phone:423-605-0367
Mailing Address - Fax:
Practice Address - Street 1:8101 E BRAINERD RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-4302
Practice Address - Country:US
Practice Address - Phone:423-508-1194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000011185183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist