Provider Demographics
NPI:1497362545
Name:WILT, LANIE FRANCES (LAC)
Entity Type:Individual
Prefix:
First Name:LANIE
Middle Name:FRANCES
Last Name:WILT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 HIGGINS AVE
Mailing Address - Street 2:
Mailing Address - City:BRIELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08730-1480
Mailing Address - Country:US
Mailing Address - Phone:732-292-9900
Mailing Address - Fax:
Practice Address - Street 1:629 HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:BRIELLE
Practice Address - State:NJ
Practice Address - Zip Code:08730-1480
Practice Address - Country:US
Practice Address - Phone:732-292-9900
Practice Address - Fax:732-292-3285
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ027177171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist