Provider Demographics
NPI:1568933869
Name:LANE, KIMBERLY DIANE (RN)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DIANE
Last Name:LANE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 VAN ZANDT COUNTY ROAD 3812
Mailing Address - Street 2:
Mailing Address - City:WILLS POINT
Mailing Address - State:TX
Mailing Address - Zip Code:75169
Mailing Address - Country:US
Mailing Address - Phone:214-507-0900
Mailing Address - Fax:
Practice Address - Street 1:1455 VAN ZANDT COUNTY ROAD 3812
Practice Address - Street 2:
Practice Address - City:WILLS POINT
Practice Address - State:TX
Practice Address - Zip Code:75169
Practice Address - Country:US
Practice Address - Phone:214-507-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-12
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX847495163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse