Provider Demographics
NPI:1578502134
Name:LANE, MARYELLEN C (NNP)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:C
Last Name:LANE
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3000
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-3000
Mailing Address - Country:US
Mailing Address - Phone:910-715-2085
Mailing Address - Fax:910-715-2137
Practice Address - Street 1:155 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8710
Practice Address - Country:US
Practice Address - Phone:910-715-2085
Practice Address - Fax:910-715-1237
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC123435363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000353Medicaid