Provider Demographics
NPI:1457131955
Name:LANE, TIJUANA THERESA
Entity Type:Individual
Prefix:MRS
First Name:TIJUANA
Middle Name:THERESA
Last Name:LANE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 VASSAR RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-5236
Mailing Address - Country:US
Mailing Address - Phone:856-287-3578
Mailing Address - Fax:
Practice Address - Street 1:535 CINNAMINSON AVE
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:NJ
Practice Address - Zip Code:08065-1610
Practice Address - Country:US
Practice Address - Phone:856-287-3578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier