Provider Demographics
NPI:1255707907
Name:LANE, MALYNDA CHRISTINE (FNP-BC)
Entity type:Individual
Prefix:
First Name:MALYNDA
Middle Name:CHRISTINE
Last Name:LANE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1513
Mailing Address - Country:US
Mailing Address - Phone:636-352-9215
Mailing Address - Fax:
Practice Address - Street 1:1000 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1513
Practice Address - Country:US
Practice Address - Phone:636-528-3486
Practice Address - Fax:636-528-3419
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016023910363LA2200X, 363LF0000X
CA95001746363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily