Provider Demographics
NPI:1265011076
Name:LANE, SHANNON ELIZABETH
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 PINEHURST PARK DR APT 4068
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5222
Mailing Address - Country:US
Mailing Address - Phone:978-660-9223
Mailing Address - Fax:
Practice Address - Street 1:310 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4289
Practice Address - Country:US
Practice Address - Phone:800-461-1398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF04210223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily