Provider Demographics
NPI:1972667517
Name:LANE, TERESA KAY (RN, MSN, CPNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:KAY
Last Name:LANE
Suffix:
Gender:F
Credentials:RN, MSN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 EASTBROOK BND
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1530
Mailing Address - Country:US
Mailing Address - Phone:770-487-3330
Mailing Address - Fax:770-487-7736
Practice Address - Street 1:12 EASTBROOK BND
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1530
Practice Address - Country:US
Practice Address - Phone:770-487-3330
Practice Address - Fax:770-487-7736
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN163766363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner