Provider Demographics
NPI:1134403082
Name:LANE, MICHELLE ANN (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN
Last Name:LANE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4232
Mailing Address - Country:US
Mailing Address - Phone:503-581-1198
Mailing Address - Fax:503-339-9565
Practice Address - Street 1:1655 STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4232
Practice Address - Country:US
Practice Address - Phone:503-581-1198
Practice Address - Fax:503-339-9565
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201150144NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500640317Medicaid