Provider Demographics
NPI:1497318844
Name:LANE, NICOLE (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 KEVESTA AVE
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-2577
Mailing Address - Country:US
Mailing Address - Phone:570-617-5915
Mailing Address - Fax:
Practice Address - Street 1:6225 KEVESTA AVE
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-2577
Practice Address - Country:US
Practice Address - Phone:570-617-5915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-20
Last Update Date:2019-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist