Provider Demographics
NPI:1245702299
Name:LANE, BETH BAILEY
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:BAILEY
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:ANNE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 MED TECH PKWY STE 108
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2278
Mailing Address - Country:US
Mailing Address - Phone:423-915-5033
Mailing Address - Fax:
Practice Address - Street 1:200 MED TECH PKWY STE 108
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2278
Practice Address - Country:US
Practice Address - Phone:423-915-5033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN183464163W00000X
TN24152363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse