Provider Demographics
NPI:1093765232
Name:LANE, KIMBERLY J (APRN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:LANE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 POMFRET ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:860-928-6541
Mailing Address - Fax:860-963-6393
Practice Address - Street 1:320 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1836
Practice Address - Country:US
Practice Address - Phone:860-928-6541
Practice Address - Fax:860-963-6393
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000708363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4007084Medicaid
CT000708OtherAPRN LICENSE NUMBER
CT000708OtherAPRN LICENSE NUMBER
CT4007084Medicaid