Provider Demographics
NPI:1114468527
Name:LANE, NICOLE R (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:LANE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 411895
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64141-1895
Mailing Address - Country:US
Mailing Address - Phone:913-632-2230
Mailing Address - Fax:913-632-2297
Practice Address - Street 1:9100 W 74TH ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-4004
Practice Address - Country:US
Practice Address - Phone:913-632-2230
Practice Address - Fax:913-789-3191
Is Sole Proprietor?:No
Enumeration Date:2017-03-17
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS139473163W00000X
PARN620227163W00000X
MO2016037397163W00000X
KS557528367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO910056108Medicaid
KS55112011OtherBCBS KC
KS201170340AMedicaid
KSP01943603OtherRAILROAD