Provider Demographics
NPI:1790561769
Name:LANE, TERRIE ANN
Entity Type:Individual
Prefix:
First Name:TERRIE
Middle Name:ANN
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 1:601 EAST JACKSON
Mailing Address - Street 2:601 EAST JACKSON
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743
Mailing Address - Country:US
Mailing Address - Phone:903-706-8224
Mailing Address - Fax:
Practice Address - Street 1:601 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4024
Practice Address - Country:US
Practice Address - Phone:903-706-8224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator