Provider Demographics
NPI:1790271211
Name:LANE, MISTY (OD)
Entity Type:Individual
Prefix:MISS
First Name:MISTY
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 OAKVALE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-3829
Mailing Address - Country:US
Mailing Address - Phone:304-425-2444
Mailing Address - Fax:304-425-2446
Practice Address - Street 1:324 OAKVALE RD STE 100
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3829
Practice Address - Country:US
Practice Address - Phone:304-425-2444
Practice Address - Fax:304-425-2446
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2048-IOD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist