Provider Demographics
NPI:1518679869
Name:LANE, MCKINZIE NICOLE (OTA)
Entity Type:Individual
Prefix:
First Name:MCKINZIE
Middle Name:NICOLE
Last Name:LANE
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ATKINS
Mailing Address - State:AR
Mailing Address - Zip Code:72823-4149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:408 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:ATKINS
Practice Address - State:AR
Practice Address - Zip Code:72823-4149
Practice Address - Country:US
Practice Address - Phone:479-495-0651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1713224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant