Provider Demographics
NPI:1295130839
Name:LANE, MARY ELIZABETH (WHNP-BC, MSN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:LANE
Suffix:
Gender:F
Credentials:WHNP-BC, MSN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:YARBRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1181 FIRST COLONIAL RD
Mailing Address - Street 2:STE 200
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2437
Mailing Address - Country:US
Mailing Address - Phone:757-425-1600
Mailing Address - Fax:
Practice Address - Street 1:1350A CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2408
Practice Address - Country:US
Practice Address - Phone:864-455-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19119363LX0001X
VA0024173336363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3085Medicaid
SCSC46827951Medicare PIN