Provider Demographics
NPI:1407446073
Name:LANE, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
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 1:144 PENN CIR
Mailing Address - Street 2:
Mailing Address - City:GALIVANTS FERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29544-8678
Mailing Address - Country:US
Mailing Address - Phone:843-433-2331
Mailing Address - Fax:
Practice Address - Street 1:144 PENN CIR
Practice Address - Street 2:
Practice Address - City:GALIVANTS FERRY
Practice Address - State:SC
Practice Address - Zip Code:29544-8678
Practice Address - Country:US
Practice Address - Phone:843-433-2331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC253204163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0346490902Medicaid