Provider Demographics
NPI:1508366238
Name:LANE, MARY C
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
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 1:2613 NEILL RD # 6C
Mailing Address - Street 2:
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-0413
Mailing Address - Country:US
Mailing Address - Phone:817-401-7012
Mailing Address - Fax:
Practice Address - Street 1:11049 W HOFFMAN DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79764-9043
Practice Address - Country:US
Practice Address - Phone:432-385-7790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX155277164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse