Provider Demographics
NPI:1942744222
Name:LANE, NICOLE RENEA (NP ADULT GERONTOLOGY)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEA
Last Name:LANE
Suffix:
Gender:F
Credentials:NP ADULT GERONTOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 BROOKHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-9634
Mailing Address - Country:US
Mailing Address - Phone:316-371-6761
Mailing Address - Fax:
Practice Address - Street 1:12401 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5443
Practice Address - Country:US
Practice Address - Phone:314-390-0135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS77185363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner