Provider Demographics
NPI:1568735652
Name:LANE, MELISSA MARLENE (DPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARLENE
Last Name:LANE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MARLENE
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7109 DONA ADELINA AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-3586
Mailing Address - Country:US
Mailing Address - Phone:505-903-1210
Mailing Address - Fax:
Practice Address - Street 1:7109 DONA ADELINA AVE SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-3586
Practice Address - Country:US
Practice Address - Phone:505-903-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4086225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist