Provider Demographics
NPI:1326727199
Name:LANE, LINDA (RDLD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 CAPTAIN QUARTERS DR
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-4922
Mailing Address - Country:US
Mailing Address - Phone:270-584-2723
Mailing Address - Fax:
Practice Address - Street 1:124 CAPTAIN QUARTERS DR
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-4922
Practice Address - Country:US
Practice Address - Phone:270-584-2723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2508133V00000X
IL725057133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered