Provider Demographics
NPI:1871634683
Name:LANE, MARY PENFIELD (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:PENFIELD
Last Name:LANE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5369 PINEYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-3424
Mailing Address - Country:US
Mailing Address - Phone:205-991-6426
Mailing Address - Fax:
Practice Address - Street 1:5369 PINEYWOOD RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-3424
Practice Address - Country:US
Practice Address - Phone:205-991-6426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-025087363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51529456OtherBCBS OF AL
AL51556190OtherBCBS OF AL
AL51529456OtherBCBS OF AL