Provider Demographics
NPI:1790039410
Name:LANE, RENEE KATHLEEN (OD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:KATHLEEN
Last Name:LANE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:KATHLEEN
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:5397 OAK GROVE CHURCH RD
Mailing Address - Street 2:PO BOX 37
Mailing Address - City:LONEDELL
Mailing Address - State:MO
Mailing Address - Zip Code:63060-1025
Mailing Address - Country:US
Mailing Address - Phone:636-744-5467
Mailing Address - Fax:
Practice Address - Street 1:12862 STATE ROUTE 21
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-4742
Practice Address - Country:US
Practice Address - Phone:636-586-9745
Practice Address - Fax:636-586-0901
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-02
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012037795152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist