Provider Demographics
NPI:1790948727
Name:LANE, AUTUMN LEA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:LEA
Last Name:LANE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHILDRENS DRIVE
Mailing Address - Street 2:J4 NICU NNP PROGRAM
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205
Mailing Address - Country:US
Mailing Address - Phone:614-722-6510
Mailing Address - Fax:722-722-4772
Practice Address - Street 1:700 CHILDRENS DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205
Practice Address - Country:US
Practice Address - Phone:614-722-6510
Practice Address - Fax:722-722-4772
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBAUI04325570363LN0005X
OHNP08976363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care