Provider Demographics
NPI:1659475911
Name:LANE, AMY MICHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:LANE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:79 BRIAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-6440
Mailing Address - Country:US
Mailing Address - Phone:860-823-0245
Mailing Address - Fax:860-213-8350
Practice Address - Street 1:79 BRIAR HILL RD
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-6440
Practice Address - Country:US
Practice Address - Phone:860-823-0245
Practice Address - Fax:860-213-8350
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002158363LP0808X, 364SF0001X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235942Medicaid
500000779Medicare ID - Type Unspecified
S76953Medicare UPIN
CTD400011232Medicare PIN