Provider Demographics
NPI:1285640359
Name:LANE, WAQUITA NICOLE (MPT)
Entity Type:Individual
Prefix:MS
First Name:WAQUITA
Middle Name:NICOLE
Last Name:LANE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:NC
Mailing Address - Zip Code:27839-0092
Mailing Address - Country:US
Mailing Address - Phone:252-583-3681
Mailing Address - Fax:
Practice Address - Street 1:2413 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-3221
Practice Address - Country:US
Practice Address - Phone:252-535-3028
Practice Address - Fax:252-535-4775
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist