Provider Demographics
NPI:1427572163
Name:LANE, KELLY MICHELE (AT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELE
Last Name:LANE
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49284-9517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 W MAIN ST APT 2B
Practice Address - Street 2:
Practice Address - City:SPRINGPORT
Practice Address - State:MI
Practice Address - Zip Code:49284-9517
Practice Address - Country:US
Practice Address - Phone:517-214-9511
Practice Address - Fax:517-214-9511
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI225A2300XOtherATHLETIC TRAINER