Provider Demographics
NPI:1770638397
Name:LANE, TERESA PARHAM (PMHCNS, FNP)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:PARHAM
Last Name:LANE
Suffix:
Gender:F
Credentials:PMHCNS, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 BRIAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-1220
Mailing Address - Country:US
Mailing Address - Phone:404-663-6400
Mailing Address - Fax:
Practice Address - Street 1:420 BRIAR CREEK RD
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-1220
Practice Address - Country:US
Practice Address - Phone:404-663-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN74324363LF0000X
GARN074324364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS10294Medicare UPIN
GA511I500927Medicare UPIN