Provider Demographics
NPI:1649580887
Name:LANE, MIRANDA KAYE (LPN)
Entity type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:KAYE
Last Name:LANE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4933 RIVER TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-5755
Mailing Address - Country:US
Mailing Address - Phone:614-853-4015
Mailing Address - Fax:
Practice Address - Street 1:4933 RIVER TRAIL CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-5755
Practice Address - Country:US
Practice Address - Phone:614-853-4015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.135967-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse