Provider Demographics
NPI:1205360021
Name:LANE, CYRENAH NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:CYRENAH
Middle Name:NICOLE
Last Name:LANE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 N 7TH ST STE 140E
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3270
Mailing Address - Country:US
Mailing Address - Phone:229-276-3100
Mailing Address - Fax:
Practice Address - Street 1:116 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3210
Practice Address - Country:US
Practice Address - Phone:229-276-3677
Practice Address - Fax:229-276-3679
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA84720207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003192565CMedicaid