Provider Demographics
NPI:1669434668
Name:LANE, CRISTY M (MS FNP)
Entity type:Individual
Prefix:MRS
First Name:CRISTY
Middle Name:M
Last Name:LANE
Suffix:
Gender:F
Credentials:MS FNP
Other - Prefix:MISS
Other - First Name:CRISTY
Other - Middle Name:M
Other - Last Name:WILLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:615 N PROMENADE ST
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:IL
Mailing Address - Zip Code:62644-1243
Mailing Address - Country:US
Mailing Address - Phone:309-543-6600
Mailing Address - Fax:309-543-2089
Practice Address - Street 1:120 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ELMWOOD
Practice Address - State:IL
Practice Address - Zip Code:61529
Practice Address - Country:US
Practice Address - Phone:309-742-2921
Practice Address - Fax:309-742-8411
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003603363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL198663OtherHEALTHLINK
500011117OtherRR MEDICARE
IL099052OtherHEALTH ALLIANCE
IL7200613OtherBCBS OF ILLINOIS
IL099052OtherHEALTH ALLIANCE
IL7200613OtherBCBS OF ILLINOIS