Provider Demographics
NPI:1649464348
Name:LANE, KENYONA
Entity type:Individual
Prefix:MS
First Name:KENYONA
Middle Name:
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 1:14950 POTOMAC HEIGHTS PL APT 204
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-6247
Mailing Address - Country:US
Mailing Address - Phone:704-577-4576
Mailing Address - Fax:
Practice Address - Street 1:14950 POTOMAC HEIGHTS PL APT 204
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-6247
Practice Address - Country:US
Practice Address - Phone:704-577-4576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040095141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical