Provider Demographics
NPI:1720622509
Name:LANE, JESSICA CHANDI (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:CHANDI
Last Name:LANE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:CHANDI
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2601 LAKESIDE PKWY STE 180
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-4291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2601 LAKESIDE PKWY STE 180
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-4291
Practice Address - Country:US
Practice Address - Phone:927-874-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143501363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner