Provider Demographics
NPI:1720753890
Name:LANE, SAMANTHA LYNN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
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 1:10267 IVYDALE RD
Mailing Address - Street 2:
Mailing Address - City:IVYDALE
Mailing Address - State:WV
Mailing Address - Zip Code:25113-8348
Mailing Address - Country:US
Mailing Address - Phone:304-441-7300
Mailing Address - Fax:
Practice Address - Street 1:15 BANK ST
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043
Practice Address - Country:US
Practice Address - Phone:304-587-9992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant