Provider Demographics
NPI:1568136844
Name:LANE, NICKOLONDRIA (ATC)
Entity Type:Individual
Prefix:
First Name:NICKOLONDRIA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5118 LONE TREE DR
Mailing Address - Street 2:
Mailing Address - City:FULSHEAR
Mailing Address - State:TX
Mailing Address - Zip Code:77441-2206
Mailing Address - Country:US
Mailing Address - Phone:832-563-7537
Mailing Address - Fax:
Practice Address - Street 1:4250 COOK RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77072-1115
Practice Address - Country:US
Practice Address - Phone:832-563-7537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX193792183700000X
TXAT47542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No183700000XPharmacy Service ProvidersPharmacy Technician