Provider Demographics
NPI:1235399189
Name:LANE, MARY KRISTINA (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KRISTINA
Last Name:LANE
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 HIGHWAY 287
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058-9682
Mailing Address - Country:US
Mailing Address - Phone:501-733-2997
Mailing Address - Fax:
Practice Address - Street 1:4300 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5446
Practice Address - Country:US
Practice Address - Phone:501-257-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1090133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered