Provider Demographics
NPI:1710465299
Name:LANE, AMY NELLIE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:NELLIE
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:WYNANTSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12198-7458
Mailing Address - Country:US
Mailing Address - Phone:845-518-4471
Mailing Address - Fax:
Practice Address - Street 1:8 CENTURY HILL DR
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2193
Practice Address - Country:US
Practice Address - Phone:518-783-7173
Practice Address - Fax:518-783-5426
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343195363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily