Provider Demographics
NPI:1023332269
Name:LANE, AMY MARIE (MS, CCC-A)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:LANE
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 NE SUWANNEE DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-1381
Mailing Address - Country:US
Mailing Address - Phone:816-686-7708
Mailing Address - Fax:
Practice Address - Street 1:4200 NE SUWANNEE DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-1381
Practice Address - Country:US
Practice Address - Phone:816-686-7708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-03-31
Deactivation Date:2010-01-28
Deactivation Code:
Reactivation Date:2010-03-17
Provider Licenses
StateLicense IDTaxonomies
MO2002028924231H00000X
KS2003231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO336016308Medicaid
KS100449020AMedicaid
P78702Medicare UPIN
KS100449020AMedicaid