Provider Demographics
NPI:1578837506
Name:LANE, KATHLEEN M (FNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:LANE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12591 CRYSTAL RANCH RD
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-2913
Mailing Address - Country:US
Mailing Address - Phone:805-523-7694
Mailing Address - Fax:
Practice Address - Street 1:5297 MAUREEN LN
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-7125
Practice Address - Country:US
Practice Address - Phone:805-531-6481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA309939363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily