Provider Demographics
NPI:1669756177
Name:LANE, MCTISA MICHELLE (FNP)
Entity type:Individual
Prefix:
First Name:MCTISA
Middle Name:MICHELLE
Last Name:LANE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:BLDG 5-4257 BASTOGNE ST
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-8862
Mailing Address - Country:US
Mailing Address - Phone:910-907-2575
Mailing Address - Fax:910-907-9606
Practice Address - Street 1:2817 REILLY ST
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-4056
Practice Address - Country:US
Practice Address - Phone:910-907-2575
Practice Address - Fax:910-907-9606
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5005342363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily