Provider Demographics
NPI:1891824108
Name:LANE, TANDA NICHOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:TANDA
Middle Name:NICHOLE
Last Name:LANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 BROOKSTONE CENTRE PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-2954
Mailing Address - Country:US
Mailing Address - Phone:706-322-1717
Mailing Address - Fax:706-322-1718
Practice Address - Street 1:1210 BROOKSTONE CENTRE PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-2954
Practice Address - Country:US
Practice Address - Phone:706-322-1717
Practice Address - Fax:706-322-1718
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000893207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology