Provider Demographics
NPI:1457932337
Name:LANE, MICHAEL JENNINGS SR (DNP PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JENNINGS
Last Name:LANE
Suffix:SR
Gender:M
Credentials:DNP PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11503 W 151ST AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9077
Mailing Address - Country:US
Mailing Address - Phone:708-269-5263
Mailing Address - Fax:
Practice Address - Street 1:6625 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-9678
Practice Address - Country:US
Practice Address - Phone:219-922-8051
Practice Address - Fax:219-922-8608
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041354134163WE0003X
IN28230854A163WP0807X
IL209023083363LP0808X
IN71011081A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent