Provider Demographics
NPI:1528587615
Name:JUDGE, LANE BERNICE (FNP-C)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:BERNICE
Last Name:JUDGE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4057 CHERYL DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-1759
Mailing Address - Country:US
Mailing Address - Phone:248-660-4981
Mailing Address - Fax:
Practice Address - Street 1:15506 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-5520
Practice Address - Country:US
Practice Address - Phone:734-682-5243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704316371363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily