Provider Demographics
NPI:1750054045
Name:WILSON, LANE E (MS, RD)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 NE 34TH LN
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-7356
Mailing Address - Country:US
Mailing Address - Phone:217-714-0203
Mailing Address - Fax:
Practice Address - Street 1:1721 NE 34TH LN
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-7356
Practice Address - Country:US
Practice Address - Phone:217-714-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-01
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered