Provider Demographics
NPI:1356600191
Name:GUNNELL, LANE
Entity type:Individual
Prefix:
First Name:LANE
Middle Name:
Last Name:GUNNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 BIRCH ST
Mailing Address - Street 2:3000 WEST TOWER
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2127
Mailing Address - Country:US
Mailing Address - Phone:888-835-0894
Mailing Address - Fax:
Practice Address - Street 1:205 MOONGLOW AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-3339
Practice Address - Country:US
Practice Address - Phone:575-434-4510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6695122-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant