Provider Demographics
NPI:1215376751
Name:LANE, ANN BOURGEOIS (CRNP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:BOURGEOIS
Last Name:LANE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNP
Mailing Address - Street 1:1321 HUNTSVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3603
Mailing Address - Country:US
Mailing Address - Phone:931-297-2201
Mailing Address - Fax:931-297-2206
Practice Address - Street 1:101 BOB WALLACE AVE SW STE E
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3843
Practice Address - Country:US
Practice Address - Phone:256-539-5339
Practice Address - Fax:256-536-5111
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000019106363LF0000X
AL1-035725363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily