Provider Demographics
NPI:1891114559
Name:LANE, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
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 1:209 DOE CIR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:GA
Mailing Address - Zip Code:31329-9226
Mailing Address - Country:US
Mailing Address - Phone:912-436-2718
Mailing Address - Fax:
Practice Address - Street 1:209 DOE CIR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:GA
Practice Address - Zip Code:31329-9226
Practice Address - Country:US
Practice Address - Phone:912-436-2718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program