Provider Demographics
NPI:1306378856
Name:LANE, KRISTOPHER OLEN (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:OLEN
Last Name:LANE
Suffix:
Gender:M
Credentials:FNP
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 1090
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1090
Mailing Address - Country:US
Mailing Address - Phone:843-857-0111
Mailing Address - Fax:
Practice Address - Street 1:122 LATIMER ST
Practice Address - Street 2:
Practice Address - City:LATTA
Practice Address - State:SC
Practice Address - Zip Code:29565-1828
Practice Address - Country:US
Practice Address - Phone:843-627-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20909363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCA484OtherMEDICARE
SCNP4553Medicaid