Provider Demographics
NPI:1982009049
Name:LANE, CORNELIA (AG-ACNP)
Entity type:Individual
Prefix:
First Name:CORNELIA
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E GROVER ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3917
Mailing Address - Country:US
Mailing Address - Phone:980-487-3678
Mailing Address - Fax:980-487-3294
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-953-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007296363LA2100X
FLAPRN11040095363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQNP283Medicaid
NC1982009049Medicaid
SCQNP283Medicaid
NCNCL561AMedicare PIN
NCNCL561CMedicare PIN
NCNCL561EMedicare PIN
NC1982009049Medicaid